Journal of Cardiovascular Nursing

Vol. 26, No. 2, pp 99Y105 x Copyright B 2011 Wolters Kluwer Health | Lippincott Williams & Wilkins

The Impact of Sleep Quality and Daytime

Sleepiness on Global Quality of Life in
Community-Dwelling Patients With
Heart Failure
Ju-Chi Liu, MD, PhD; Hsiang-Lien Hung, MSN; Yuh-Kae Shyu, MSN; Pei-Shan Tsai, PhD

Background and Research Objective: Although it is well established that symptom burden in heart failure (HF)
often leads to poor health-related quality of life (QOL), the contributions of quality of sleep and daytime sleepiness
to the overall perception and satisfaction with life in the HF population have yet to be determined. We thus tested
the hypothesis that quality of sleep and daytime sleepiness are significant predictors of QOL as measured by the
World Health Organization Quality of LifeYBREF (WHOQOL-BREF) in patients with HF. Subjects and Methods:
Included were 88 medically stable patients with echocardiographically documented HF. This cross-sectional study
used a correlational design, and data were collected using self-report questionnaires including the Chinese version
of the Pittsburgh Sleep Quality Index (CPSQI), Epworth Sleepiness Scale, and WHOQOL-BREF Taiwan version.
Multiple linear regression analyses were used to address the study hypotheses. Results and Conclusions: With
the exception of the environmental domain (P = .078), poor sleepers had significantly lower scores in physical
(P G .001), psychological (P = .001), and social (P = .040) domains of the WHOQOL-BREF. Multivariate regression
analysis revealed that age, CPSQI, perceived health status, and comorbidities significantly predicted the physical
QOL (adjusted R2 = 0.59, P G .001). For the psychological QOL, only perceived health status and CPSQI score
remained in the regression model (adjusted R2 = 0.28, P = .016). For the environmental QOL, perceived health
status and Epworth Sleepiness Scale were the only predictors remaining in the model (adjusted R2 = 0.17,
P G .001). The findings from this study add support to the evidence that in medically stable persons with HF, poor
sleep independently predicts the overall perception and satisfaction with life, in particular, in the physical and
psychological domains of QOL, whereas daytime sleepiness independently predicts the environmental QOL.
KEY WORDS: daytime sleepiness, heart failure, quality of life, quality of sleep

Ju-Chi Liu, MD, PhD

Associate Professor and Director, Division of Cardiovascular Medicine, Taipei
Medical University Shuang-Ho Hospital, Taipei County, Taiwan; School of
Medicine, College of Medicine, Taipei Medical University, Taipei, Taiwan.
Hsiang-Lien Hung, MSN
Head Nurse, Graduate Institute of Nursing, College of Nursing, Taipei
Medical University, Taipei, Taiwan; Department of Nursing, Taipei
Medical University Wan Fang Hospital, Taipei, Taiwan.
Yuh-Kae Shyu, MSN
Doctorate Student, Graduate Institute of Nursing, College of
Nursing, Taipei Medical University, Taipei, Taiwan.
Pei-Shan Tsai, PhD
Professor, Graduate Institute of Nursing, College of Nursing, Taipei
Medical University, Taipei, Taiwan; Department of Nursing, Taipei
Medical University Wan Fang Hospital, Taipei, Taiwan; Sleep Science
Center, Taipei Medical University Hospital, Taipei, Taiwan.
J.-C.L. and H.-L.H. are equal-contribution first authors.
This study was supported by a grant from Taipei Medical University
Wan Fang Hospital (95TMU-WFH-14).
Correspondence
Pei-Shan Tsai, PhD, Graduate Institute of Nursing, College of
Nursing, Taipei Medical University, 250 Wu Hsing St, Taipei 110,
Taiwan (ptsai@tmu.edu.tw).
DOI: 10.1097/JCN.0b013e3181ed7d12
P oor sleep has a profound impact on a person’s psy-
chological well-being1 and quality of life (QOL).2,3
Thus, improving QOL has long been an implicit, but
not explicit, goal of interventions to improve quality
of sleep (QOS). Sleep complaints are common in
patients with chronic disease including heart failure
(HF).4 In view of a growing recognition of the impor-
tance of patient-centered outcomes, such as patient
satisfaction and QOL,5 it is important to examine the
impact of QOS on QOL in patients with HF.
Poor sleep is independently associated with poor
health-related QOL (HRQOL) in patients with chronic
illness.4 Among the HF patients, those with poor QOS
reported significantly lower HRQOL than those with-
out.6 However, the impact of poor QOS on global
QOL, taking the impact of confounders into consid-
eration, has not yet been adequately studied in pa-
tients with HF. To this end, QOS in this study was
assessed using the Pittsburgh Sleep Quality Index
(PSQI), which was developed to measure sleep qual-
ity during the previous month and to discriminate

99

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100 Journal of Cardiovascular Nursing x March/April 2011
between good and poor sleepers.7 Quality of life in
this study was defined as an individual’s physical,
psychological, social, and environmental well-being
in the context of his/her culture and value systems
and his/her personal goals, standards, and concerns.8
Daytime sleepiness is a subjective perception of the
propensity to sleep during the day, which has been
commonly estimated by the Epworth Sleepiness Scale
(ESS).9 Daytime sleepiness is a highly prevalent self-
reported symptom in poor sleepers1 but had received
less attention in the HF population. Of the HF pa-
tients studied, 21% had daytime sleepiness as assessed
by the ESS in a previous study.6 We tested the hy-
pothesis that the HF patients with poor QOS have
significantly higher levels of daytime sleepiness than
those with good QOS. Although it is well established
that symptom burden in HF often leads to poor
HRQOL,10 the contributions of QOS and daytime sleep-
iness to the overall perception and satisfaction with
life in the HF population have yet to be determined.
We thus tested the hypothesis that subjective QOS
and daytime sleepiness are significant predictors of
QOL as measured by the World Health Organization
Quality of LifeYBREF (WHOQOL-BREF) question-
naire in patients with HF.
Methods
Design
This cross-sectional study used a correlational design,
and data were collected using self-report questionnaires.
Study Participants
A purposive sample of community-dwelling patients
with systolic or diastolic HF was recruited from a car-
diology outpatient clinic in a medical center located in
northern Taiwan. Subjects were eligible if they were
30 years or older, had a diagnosis of HF of more than
3 months, were receiving a stable medication regimen
for at least 2 months, could communicate in Mandarin
or Taiwanese, and had a New York Heart Association
(NYHA) functional class I or II. Subjects were ex-
cluded if they were shift workers, were admitted to the
hospital at the time of data collection, or had a history
of a major psychiatric disorder, severe chronic obstruc-
tive pulmonary disease, malignant neoplasm, demen-
tia, and Parkinson disease. Participation was delayed
if potential participants had a recent hospitalization
(within 1 month of enrollment) or a recent (within 6
months of enrollment) coronary artery bypass surgery
or coronary intervention (angioplasty, stent, atherec-
tomy, or laser).
Each potential participant was seen by a cardiolo-
gist to verify the eligibility to participate in the study.
Copyright @ 2011 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
Briefly, medical history was obtained trough a thor-
ough history taking and chart review. Signs and symp-
toms of HF and an abnormal echocardiography (ie,
left ventricular [LV] ejection fraction G50% for im-
paired LV systolic function and/or mitral inflow E/A
ratio G1 assessed by Doppler technique for impaired
LV diastolic function) were used to confirm the di-
agnosis of HF. Severe chronic obstructive pulmonary
disease was defined based on a pulmonary function
test, indicating the ratio of forced expiratory volume in
1 second (FEV1) to forced vital capacity of less than
0.70 and 30% e FEV1 G 50% predicted. Included in
the study were 88 men and women with HF.
Instruments
Chinese Version of the PSQI
The PSQI is a self-report questionnaire that assesses
multiple dimensions of sleep over a 1-month period.7,11
Nineteen individual items generate 7 ‘‘component’’
scores: subjective sleep quality, sleep latency, sleep
duration, habitual sleep efficiency, sleep disturbances,
use of sleeping medication, and daytime dysfunction.
The sum of the 7 component scores yields 1 global
score of subjective QOS (range, 0Y21); higher scores
represent poorer subjective QOS. The PSQI had been
used to assess self-reported QOS in patients with
HF.12 A Chinese version of the PSQI (CPSQI) was
used to assess QOS in this study, which has been
previously developed and validated.13
The Epworth Sleepiness Scale
Epworth Sleepiness Scale, a subjective measurement of
sleepiness, is a self-report questionnaire. It measures
the likelihood of dozing off under certain environ-
mental conditions in daily life in the recent weeks9 and
had been used to assess self-reported daytime sleepi-
ness in patients with HF.6,14 There are 8 items cor-
responding to 8 conditions. These items are rated on
a scale of 0 to 3, with a score of 10 or greater indi-
cating excessive daytime sleepiness (EDS). The Chi-
nese version of the ESS was used in this study, which
has been validated in a previous study.15
The WHOQOL-BREF Taiwan Version
The brief version of the World Health Organization
Quality of Life (WHOQOL-BREF) questionnaire con-
tains 28 items, with each item representing one facet of
life that is considered to have contributed to a person’s
QOL.16 Among those 28 items, 24 of them assess 4
domains of QOLVphysical health (7 items), psycho-
logical health (6 items), social relationships (4 items),
and environment (9 items); 1 item measures overall
QOL, and 1 item measures general health. Two
national items that measure Taiwan-specific QOL

are included in the environment domain and the
social relationship domains.16 All domain scores were
calculated by taking the mean score for all items
included in each domain and multiplying by a factor
of 4. The score for each domain therefore ranged
from 4 to 20, with a higher score indicating better
QOL. The score of each domain was then converted
to a P score with 0- to 100-point score range using the
following formula: P = (x j 4 / 20 j 4)  100, where
x is the actual domain score.17
Data Collection and Analysis
Sociodemographic and lifestyle data included age, body
height, weight, sex, marital status, educational level,
personal monthly income in Taiwan dollar (NT), re-
ligion, and habits of smoking and alcohol consumption.
Comorbid diseases investigated included diabetes,
hypertension, skeletomuscular disease, hepatobiliary
and pancreatic disease, gastrointestinal disease, kid-
ney disease, and cerebrovascular accident. Information
regarding use of "-blockers, angiotensin-converting en-
zyme inhibitors (ACEIs), and diuretics was also col-
lected. Perceived health status was assessed using a
5-point Likert-type question, with 1 indicating very
poor health and 5 indicating very good health. For data
analysis, perceived health was recoded into 3 catego-
ries: ‘‘poor,’’ ‘‘on average,’’ and ‘‘good.’’ All participants
completed the CPSQI, ESS, and the WHOQOL-BREF
questionnaires. Ninety-seven subjects consented to par-
ticipate in the study. Among them, 9 subjects had 1 or
more missing data and were excluded from the analy-
sis. The final sample size was 88. Two subjects did not
provide data on perceived health status, and thus, only
86 subjects were included in the multiple regression
models.
Data were analyzed using the Statistical Package for
the Social Science (version 15.0; SPSS inc, Chicago,
Illinois). Bivariate correlations were used to examine
the relationship between variables. Multiple regression
TABLE 1 Component and Global Score of the Pittsburgh Sleep Quality Indexa
Poor Sleepers (n = 58)
c
Subjective sleep quality 1.71 (0.68)
Sleep latencyc 1.67 (0.98)
Sleep durationc 1.40 (0.95)
Habitual sleep efficiencyc 0.97 (1.17)
Sleep disturbancesc 1.52 (0.54)
Use of sleeping medicationc 1.38 (1.32)
Daytime dysfunctionc 1.19 (0.87)
Global scoreb 9.88 (3.02)
a
Values are expressed as mean (SD).
b
Group comparison was tested by independent t test in continuous data.
c
Group comparison was tested by Mann-Whitney U test in continuous data.
Copyright @ 2011 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
Quality of Sleep and Quality of Life in Chronic HF 101
analyses were used to identify predictors of global
QOL.
Results
A total of 88 subjects, aged 30 to 92 years, were in-
cluded in the study. Among this convenience sample of
patients with HF, 66% were poor sleepers (global
CPSQI 95). As expected, the 2 groups were signifi-
cantly different in all CPSQI component scores and the
global score (Table 1).
A comparison of sociodemographic data (ie, age,
weight, body mass index [BMI], sex, marital status,
education, income, and religion), lifestyle habits (ie, smok-
ing and alcohol consumption), comorbidity, use of "-
blockers, use of ACEIs, and use of diuretics between
poor and good sleepers revealed that the 2 groups were
not significantly different in any one of the charac-
teristics (all P 9 .05; Table 2). Moreover, age, weight,
BMI, sex, marital status, educational level, monthly
income, religion, smoking, alcohol consumption, use
of "-blockers, use of ACEIs, and use of diuretics were
not associated with QOS (ie, CPSQI score) as a con-
tinuous variable (all P 9 .05). The majority of the
subjects (81.8%) had 1 or more comorbid diseases.
Diabetes (P = 1.0), hypertension (P = .216), skeleto-
muscular disease (P = 1.0), hepatobiliary and pancre-
atic diseases (P = 1.0), gastrointestinal disease (P =
1.0), kidney disease (P = 1.0), cerebrovascular acci-
dent (P = 1.0), and other illness (P = 1.0) were not
significantly associated with poor QOS in the HF
patients.
Of notice was that poor sleepers had higher ESS score
than good sleepers (8.21 [SD, 5.02] vs 6.23 [SD, 3.21];
P = .016). Among the poor sleepers, 34.5% had an ESS
score of 10 or greater, whereas in good sleepers, only
16.7% had an ESS score of 10 or greater. Neither
weight nor BMI significantly correlated to ESS score
(P = .327 and .316, respectively). Those who were
taking "-blockers, ACEIs, and diuretics and those who
Sleep Quality
Good Sleepers (n = 30) P
0.83 (0.53) G.001
0.37 (0.56) G.001
0.73 (0.79) .002
0.13 (0.43) G.001
1.17 (0.38) .002
0.13 (0.35) G.001
0.47 (0.57) G.001
3.83 (1.26) G.001
102 Journal of Cardiovascular Nursing x March/April 2011

TABLE 2 Distribution of Sample Characteristics

Sleep Quality
Variable Poor Sleepers (n = 58) Good Sleepers (n = 30) Pa
Age, mean (SD), y 56.67 (13.47) 56.17 (10.26) .845
Body weight, mean (SD), kg 68.60 (16.16) 70.42 (8.92) .598
BMI, mean (SD), kg/m2 26.53 (5.87) 26.03 (2.46) .614
Sex, n (%) .147
Men 22 (37.9) 17 (56.7)
Women 36 (62.1) 13 (43.3)
Marital status, n (%) .711
Yes 52 (89.7) 28 (93.3)
No 6 (10.3) 2 (6.7)
Education, n (%) .366
High school and below 38 (65.5) 15 (50)
College 17 (29.3) 13 (43.3)
Graduate and above 3 (5.2) 2 (6.7)
Monthly income (1000 NT), n (%) .383
20 26 (44.8) 9 (30)
20Y60 18 (31) 9 (30)
60Y100 8 (13.8) 8 (26.7)
Above 100 6 (10.3) 4 (13.3)
Religion, n (%) 1.000
Yes 51 (87.9) 27 (90)
No 7 (12.1) 3 (10)
Smoking group, n (%) .757
Current smoker 8 (13.8) 5 (16.7)
Nonsmoker 50 (86.2) 25 (83.3)
Alcohol consumption, n (%) .221
Yes 7 (12.1) 7 (23.3)
No 51 (87.9) 23 (76.7)
Comorbidities, n (%) .393
Yes 9 (84.5) 23 (76.7)
No 49 (15.5) 7 (23.3)
Use of "-blockers, n (%) 1.000
Yes 28 (48.3) 15 (50)
No 30 (51.7) 15 (50)
Use of ACEIs, n (%) 1.000
Yes 25 (43.1) 12 (43.3)
No 33 (56.9) 17 (56.7)
Use of diuretics, n (%) 1.000
Yes 28 (48.3) 14 (46.7)
No 30 (51.7) 16 (53.3)

Abbreviations: ACEIs, angiotensin converting enzyme inhibitors; BMI, body mass index.
a
Group comparison was tested by independent t test in continuous data and by # 2 test or Fisher exact test in categorical data.

were not taking these medications had comparable ESS respectively), but not with the psychological and
score (P = .630, .806, and .369, respectively). social domains (P 9 .05).
Poor sleepers had significantly lower scores in
TABLE 3 Domain Scores of the World Health
physical (P G .001), psychological (P = .001), and so-
cial (P = .040), but not environmental (P = .078), do- Organization Quality of Life in Poor and
mains of the WHOQOL-BREF (Table 3). Good Sleepers
Quality of sleep as measured by the CPSQI was Sleep Quality
inversely correlated with the physical and psychologi- Poor Sleepers Good Sleepers
cal domains of the WHOQOL-BREF (r = j0.65, r = Domain (n = 58) (n = 30) P
j0.41, respectively; P G .001, P G .001, respectively) Physicala
56.91 (13.76) 74.07 (11.13) G.001
but not with the social (P = .434) and environmental Psychologicala 56.72 (14.07) 67.00 (12.91) .001
(P = .072) domains. Daytime sleepiness as measured Socialb 59.21 (15.33) 66.20 (11.20) .040
by the ESS inversely correlated to the physical and Environmentala 63.22 (12.62) 68.07 (10.97) .078
environmental domains of the WHOQOL-BREF (r = a
Group comparisons were tested by independent t test.
j0.29, r = j0.29, respectively; P = .009, P = .005, b
Group comparison was tested by Mann-Whitney U test.

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TABLE 4 Predictors of the Physical Domain
Score of the WHOQOLa
" 95% Confidence
Variable Coefficient Interval
Constant 91.98 78.54 to 105.41
CPSQI j2.07 j2.66 to j1.47
Age j0.29 j0.47 to j0.11
Comorbidities (yes) j5.90 j11.46 to j0.35
Healthb
Health (1) 15.35 8.96 to 21.74
Health (2) 8.73 3.51 to 13.94
Abbreviations: CPSQI, Chinese version of the Pittsburgh Sleep Quality
Index; WHOQOL, World Health Organization Quality of Life.
a 2
R for the model is 0.62, adjusted R2 for the model is 0.59, n = 86.
b
Reference = poor health; (1) = good; (2) = on average.
As expected, the presence of comorbidities was
associated with the physical and environmental do-
mains of the WHOQOL-BREF (P = .018 and P = .037,
respectively). However, the presence of 1 or more co-
morbidities was not significantly related to the other 2
domains (P 9 .05).
As expected, perceived health status was significantly
associated with the physical (P G .001), psychological
(P G .001), social (P = .034), and environmental (P =
.004) domain scores.
Multivariate regression analysis revealed that age,
CPSQI, perceived health status, and comorbidities sig-
nificantly predicted the physical QOL. Together these
variables explained 59% of the variance of the physical
QOL (adjusted R2 = 0.59, P G .001; Table 4).
For the psychological QOL, only perceived health
status and CPSQI score remained in the regression
model (adjusted R2 = 0.28, P = 0.016; Table 5).
Marital status and perceived health status were the
only predictors of the social relations QOL (adjusted
R2 = 0.22, P G .001). For the environmental QOL,
perceived health status and ESS were the only pre-
dictors remaining in the model (adjusted R2 = 0.17,
P G .001; Table 6).
The CPSQI score was a significant predictor of
neither the social relations nor the environmental
QOL. Daytime sleepiness as measured by the ESS was
not a significant predictor of the physical, psychol-
ogical, and social QOL domain scores after socio-
demographic factors, comorbidity, perceived health
status, and QOS were accounted for in the regression
models.
Discussion
The HF population experiences a cluster of symptoms
including dyspnea, anorexia, fatigue, poor QOS, and
anxiety that often lead to poor HRQOL.18 In light of
the burden of HF on poor HRQOL and mortality, the
American Heart Association issued a scientific state-
Copyright @ 2011 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
Quality of Sleep and Quality of Life in Chronic HF 103
ment to call for the attention on the promotion of self-
care in persons with HF in 2009.19 Sleep disturbances
have been outlined by the American Heart Association
P as one of the factors that make self-care difficult for
G.001 patients with HF. In this study, we examined the impact
G.001 of self-reported QOS on global QOL in HF patients who
.002 were asymptomatic or present symptoms only after
.038 physical activity. Findings from this study supported the
notion that poor QOS is a likely target for interventions
G.001
.001 to improve QOL among patients with HF as we found
that poor sleepers had significantly lower scores in 3 of
the 4 domains of the QOL as compared with good
sleepers. The salient finding from this study was that after
adjusting for other important correlates of QOL, QOS
remained a significant predictor of both the physical and
psychological domains of the QOL in medically stable
HF patients. Poor QOS secondary to medical conditions
has often been overlooked because of the traditional
notion that the associated medical condition must be
treated first before any treatment of sleep difficulties can
be initiated. Nevertheless, nonpharmacological interven-
tions such as cognitive behavioral therapy and relaxation
have demonstrated measurable improvement in objective
and subjective QOS in older adults with sleep difficulties
secondary to medical conditions20,21 and can therefore
be applied to patients with HF. Moreover, future clinical
trials aiming at improving QOS for patients with HF
should make explicit QOL as one of the treatment ef-
ficacy outcomes.
Physical symptoms and functional status have been
identified as major predictors of poor HRQOL in patients
with HF.10 In accordance with previous findings, we
found that perceived health status was a major determi-
nant of all 4 QOL domains. Health care professionals,
including nurses, should make efforts to provide appro-
priate interventions to improve HF patients’ physical
symptom status and hopefully improve QOL.
Among the sociodemographic and lifestyle vari-
ables studied, only age and marital status were iden-
tified to be significant predictors of QOL in this study:
age partially explained the physical QOL, whereas
marital status accounted, partially, for the social
TABLE 5 Predictors of the Psychological
Domain Score of the WHOQOLa
" 95% Confidence
Variable Coefficient Interval P
Constant 59.63 50.86 to 68.40 G.001
CPSQI j0.95 j1.70 to j0.21 .013
Healthb
Health (1) 16.34 8.38 to 24.30 G.001
Health (2) 8.05 1.55 to 14.56 .016
Abbreviations: CPSQI, Chinese version of the Pittsburgh Sleep Quality
Index; WHOQOL, World Health Organization Quality of Life.
a 2
R for the model is 0.31, adjusted R2 for the model is 0.28, n = 86.
b
Reference = poor health; (1) = good; (2) = on average.
104 Journal of Cardiovascular Nursing x March/April 2011
TABLE 6 Predictors of the Environmental Domain Score of the WHOQOLa
Variable " Coefficient
Constant 68.15
ESS j0.75
Healthb
Health (1) 9.14
Abbreviations: ESS, Epworth Sleepiness Scale; WHOQOL, World Health Organization Quality of Life.
a 2
R for the model is 0.19, adjusted R2 for the model is 0.17, n = 86.
b
Reference = poor health; (1) = good.
relationship domain of the QOL. Of notice was that
in our sample all the sociodemographic and lifestyle
variables were not associated with QOS. Female sex
has been found to be associated with poor HRQOL in
HF patients.10,22 In this study, however, female sex
was not a predictor of any one of the QOL domains.
This discrepancy can be explained by the differences
in the concepts assessed between ours and previous
studies. We defined QOL as the overall perception
and satisfaction with life, whereas previous studies
assessed the HRQOL.
A previous study of the adult Taiwanese population
demonstrated that the risk of EDS was 3 times as high
for adults with sleep complaints as for those without.1
Findings from this study supported this notion and
demonstrated that among the patients with HF in
Taiwan poor sleepers had significantly higher levels of
daytime sleepiness than good sleepers. Moreover, we
found that daytime sleepiness was an independent
determinant of the environmental QOL in patients
with HF. This finding is of profound clinical implica-
tions because the environmental domain of the
WHOQOL-BREF measures important environmental
issues that affect one’s perception of general well-
being such as transportation, leisure activities, and
access to health care.8,17 HF patients with daytime
sleepiness may be less likely to participate in leisure
activities and have limited access to health care ser-
vices and thus have a lower level of satisfaction with
environmental QOL. Daytime sleepiness not only re-
duces environmental well-being as we observed but
may also impair self-care and result in depression in
persons with HF as proposed by others.23 Thus, health
care providers must use valid tools to assess the
problem of daytime sleepiness and to identify and al-
leviate factors that may cause daytime sleepiness in
this population.
Several limitations of this study must be addressed.
First, this study included HF patients with a wide age
range (30Y92 years old). Second, data on sleep dis-
ordered breathing (SDB) and on the use of sleep medi-
cations were not available. Poor QOS in HF patients
is often caused by SDB.12 Interestingly, SDB was found
to independently predict HRQOL in middle-aged
(mean age, 61 [SD, 11] years)12 but not in elderly
(970 years)14 HF patients. The significance of the study
Copyright @ 2011 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
95% Confidence Interval P
63.31 to 72.99 G.001
j1.28 to j0.22 .006
3.60 to 14.68 .002
would be strengthened had the diagnosis of SDB such
as central sleep apnea with Cheyne-Stokes respiration
and obstructive sleep apnea and the information on the
use of sleep medications been included. Third, 2 major
determinants of poor HRQOL in HF patients, fatigue
and depression,24,25 were not assessed in this study.
Therefore, the exact cause of daytime sleepiness and
the mechanisms through which poor QOS and day-
time sleepiness affect QOL could not be determined.
Fourth, this study included only patients with NYHA
functional class I or II but not markedly symptomatic
HF patients (ie, NYHA classes III and IV). Therefore,
the study findings can be generalized only to commun-
ity-dwelling HF patients without marked limitation of
activity. Lastly, this study was cross-sectional in nature.
The cause-effect relationship between QOS and QOL
could not be ascertained, and one cannot rule out the
possibility that there exists a bidirectional relation-
ship between QOS and QOL. Nevertheless, even after
adjustment for sociodemographic factors, perceived
health status, and comorbidities, subjective QOS re-
mained a significant predictor of both the physical and
psychological domains of th QOL in HF patients
without marked limitation of physical activity, whereas
self-reported daytime sleepiness was an independent
predictor of the environmental QOL.
Conclusions
The findings from this study add support to the evidence
that in persons with medically stable HF without
marked limitation of physical activity, poor QOS
independently predicts the overall perception and sat-
isfaction with life, in particular, in the physical and
psychological domains of QOL, whereas daytime sleepi-
ness independently predicts the environmental QOL.
Summary and Implications
h In community-dwelling persons with HF without
marked limitation of physical activity, self-reported
poor QOS impairs not only the HRQOL as pre-
viously demonstrated but also the overall perception
and satisfaction with life, in particular, in the physical
and psychological domains, even after taking into
consideration possible confounders of QOL.

What’s New and Important
h In community-dwelling patients with chronic HF
without marked limitation of physical activity, poor
sleep impairs not only the HRQOL as previously
demonstrated but also the overall perception and
satisfaction with life, in particular, in the physical and
psychological domains, even after taking into
consideration possible confounders of QOL.
h Patients with chronic HF with daytime sleepiness
may be less likely to participate in leisure activities
and have limited access to health care services and
thus have a lower level of satisfaction with
environmental QOL.
h Future clinical trials aiming at improving QOS for
patients with HF should make explicit QOL as one
of the treatment efficacy outcomes.
h Nonpharmacological interventions such as cognitive
behavioral therapy and relaxation should be applied
to patients who experience poor QOS secondary to
such a medical condition as HF.
h Cardiovascular nurses should make efforts to provide
appropriate interventions (eg, enhanced self-care) to
improve physical symptom status in patients with HF
and in turn improve QOL, as perceived health status
remains a major determinant of global QOL.
h HF patients with daytime sleepiness may be less
likely to participate in leisure activities and have
limited access to health care services and thus have a
lower level of satisfaction with environmental QOL.
h Health care providers, including nurses, must use
valid tools to assess the problem of daytime sleepi-
ness and to identify and alleviate factors that may
cause EDS in the HF population.
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