HEALTH-RELATED QUALITY OF LIFE INCREASES AFTER FIRST-TIME ACUTE 
MYOCARDIAL INFARCTION: A POPULATION-BASED STUDY 
Aleksandra GĄSECKA1*, Bartholomew RZEPA2, Aleksandra SKWAREK1, Agata ĆWIEK1, 
Kinga PLUTA1, Łukasz SZARPAK2,3,4, Miłosz J. JAGUSZEWSKI1, Tomasz MAZUREK1, Janusz 
KOCHMAN1, Grzegorz OPOLSKI1, Krzysztof J. FILIPIAK4, Krzysztof GĄSECKI5
1Medical University of Warsaw, 1st Chair and Department of Cardiology, Stefana Banacha 1a, Warsaw, Masovian, Poland
2Bialystok Oncology Center, Bialystok, Poland
3Polish Society of Disaster Medicine, Warsaw, Poland
4Maria Sklodowska-Curie Medical Academy in Warsaw, Warsaw, Poland 
5University of Warmia and Mazury, Faculty of Social Sciences, Chair of Social Pedagogy  
and Educational Research Methodology, Olsztyn, Poland
Received: Jan 6, 2021
Accepted: Nov 4, 2021
Original scientific article
*Corresponding author: E-mail: gaseckaa@gmail.com
10.2478/sjph-2022-0005 Zdr Varst. 2022;61(1):24-31
24
IZBOLJŠANJE Z ZDRAVJEM POVEZANE KAKOVOSTI ŽIVLJENJA PO 
PRVEM AKUTNEM MIOKARDNEM INFARKTU: POPULACIJSKA ŠTUDIJA 
© National Institute of Public Health, Slovenia. 
Gąsecka A, Rzepa B, Skwarek A, Ćwiek A, Pluta K, Szarpak Ł, Jaguszewski MJ, Mazurek T, Kochman J, Opolski G, Filipiak KJ, Gąsecki K. Health-related quality of life increases after 
first-time acute myocardial infarction: a population-based study. Zdr Varst. 2022;61(1):24-31. doi: 10.2478/sjph-2022-0005.
ABSTRACT
Keywords: 
acute myocardial 
infarction, quality of 
life, SF-36, WHOQOL 
BREF; MacNew, 
emotional health, 
mental health
IZVLEČEK
Ključne besede: 
akutni miokardni 
infarkt, kakovost 
življenja, SF-
36, WHOQOL 
BREF; MacNew, 
čustveno zdravje, 
duševno zdravje
Introduction: Acute myocardial infarction (AMI) affects patients’ health-related quality of life (HRQOL). AMI may 
decrease HRQOL, thus negatively affecting QOL. However, the improvements in interventional treatment and early 
rehabilitation after AMI may have a positive effect on HRQOL.
Aim: We evaluated HRQOL in patients after the first AMI treated in a reference cardiology centre in Poland and 
assessed which clinical variables affect HRQOL after AMI.
Material and methods: We prospectively evaluated HRQOL in 60 consecutive patients suffering after their first 
AMI during the index hospitalisation and again after 6 months, using: (i) MacNew, (ii) World Health Organization 
Quality of Life (WHOQOL) BREF, and (iii) Short Form (SF) 36.
Results: As measured by the MacNew questionnaire, global, social, and physical functioning did not change 
(p≥0.063), whereas emotional functioning improved 6 months after AMI, compared to index hospitalisation 
(p=0.002). As measured by WHOQOL BREF, physical health, psychological health, and environmental functioning 
did not change (p≥0.321), whereas social relationships improved 6 months after AMI (p=0.042). As assessed by SF-
36, the global HRQOL improved after AMI (p=0.044). Patients with improved HRQOL in SF-36 often had a higher 
baseline body mass index (p=0.046), dyslipidaemia (p=0.046), and lower left ventricle ejection fraction (LVEF; 
p=0.013). LVEF<50% was the only variable associated with improved HRQOL in multivariate analysis (OR 4.463, 95% 
CI 1.045 - 19.059, p=0.043).
Conclusions: HRQOL increased 6 months after the first AMI, especially in terms of emotional functioning and social 
relationships. Patients with LVEF<50% were likely to have improved HRQOL.
Uvod: Akutni miokardni infarkt (AMI) vpliva na z zdravjem povezano kakovost življenja pacientov. AMI lahko 
zmanjša z zdravjem povezano kakovost življenja pacientov in funkcionalno sposobnost ter s tem negativno vpliva 
na kakovost življenja. Vendar pa lahko izboljšave intervencijskega zdravljenja in zgodnja rehabilitacija po AMI 
pozitivno vplivajo na z zdravjem povezano kakovost življenja.
Cilj: Ocenili smo z zdravjem povezano kakovost življenja pri pacientih po prvem zdravljenju AMI v referenčnem 
kardiološkem centru na Poljskem in ovrednotili, katere klinične spremenljivke vplivajo na z zdravjem povezano 
kakovost življenja po AMI.
Gradiva in metode: Prospektivno smo ocenili z zdravjem povezano kakovost življenja pri 60 zaporednih pacientih 
s prvim AMI med indeksno hospitalizacijo in po 6 mesecih z uporabo: (i) vprašalnika MacNew, (ii) skrajšane različice 
vprašalnika kakovosti življenja Svetovne zdravstvene organizacije (WHOQOL-BREF) in (iii) vprašalnika SF-36.
Rezultati: Kot je bilo izmerjeno z vprašalnikom MacNew, se globalno, socialno in fizično delovanje ni spremenilo 
(p ≥ 0,063), čustveno delovanje pa se je 6 mesecev po AMI izboljšalo v primerjavi z indeksno hospitalizacijo (p 
= 0,002). Kot je bilo izmerjeno z vprašalnikom WHOQOL-BREF, se telesno zdravje, psihično zdravje in okoljsko 
delovanje niso spremenili (p ≥ 0,321), socialni odnosi pa so se v 6 mesecih po AMI izboljšali (p = 0,042). Kot je 
bilo ocenjeno z vprašalnikom SF-36, se je globalna z zdravjem povezana kakovost življenja po AMI izboljšala (p = 
0,044). Pacienti z izboljšano z zdravjem povezano kakovostjo življenja so pri vprašalniku SF-36 imeli izhodiščni 
indeks telesne mase (p = 0,046), pogostejšo dislipidemijo (p = 0,046) in nižji iztisni delež levega prekata (LVEF; p = 
0,013). LVEF < 50 % je bila edina spremenljivka, povezana z izboljšano z zdravjem povezano kakovostjo življenja, 
pri multivariatni analizi (OR 4,463, 95 % CI 1,045 – 19,059, p = 0,043).
Zaključki: Z zdravjem povezana kakovost življenja se je 6 mesecev po prvi AMI povečala, zlasti na področju 
čustvenega delovanja in socialnih odnosov. Pri pacientih z LVEF < 50 % je bila večja verjetnost, da se je z zdravjem 
povezana kakovost življenja izboljšala.
10.2478/sjph-2022-0005 Zdr Varst. 2022;61(1):24-31
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1 INTRODUCTION
Globally, an estimated 17.5 million people die annually 
from cardiovascular disease (CVD), of which 7.5 million 
deaths are attributable to coronary artery disease and 
its complications, including acute myocardial infarction 
(AMI) (1). AMI not only is one of the leading causes of 
death worldwide, but also may lead to markedly impaired 
health-related quality of life (HRQOL) (2).
In developed countries, including Poland, wide access to 
new pharmacological therapies and percutaneous coronary 
intervention (PCI) has substantially reduced mortality 
after AMI (3, 4). However, the long-term consequences 
for the HRQOL may include decreased exercise tolerance, 
dyspnoea, new arrhythmias, or other symptoms of heart 
failure (HF) present within weeks to months following AMI 
(5). Moreover, AMI might impact many other aspects of 
life quality, for example sexual activity, as we showed 
one or two decades ago (6, 7). On the other hand, recent 
improvements in AMI interventional treatment and new 
cardiological rehabilitation programs after AMI may have 
a positive effect on post-AMI QOL (8). Finally, post-AMI 
QOL may differ per country due to differences in medical, 
psychological, and social support (9).
Since the general prognosis of patients with AMI in Poland 
substantially improved in recent years, mostly due to the 
implementation of a 24-hour interventional cardiology 
service and routine cardiac rehabilitation, evaluation 
of post-AMI in Poland QOL is of particular interest (10). 
Whereas the hard clinical endpoints such as major adverse 
cardiac events and cardiovascular mortality have been 
thoroughly evaluated in clinical trials, QOL remains less 
investigated. Evaluation of QOL is crucial for healthcare 
professionals to tailor support systems to meet patients’ 
needs by offering the best treatment, as well as for public 
health specialists to offer new epidemiological solutions 
to improve HRQOL after AMI.
To further improve the quality of post-AMI care in Poland, 
we aimed to (i) evaluate the changes in HRQOL after 
AMI using three different standardized questionnaires, 
validated in the Polish population (11–13), and (ii) determine 
the clinical variables which affect HRQOL after AMI.
2 MATERIALS AND METHODS
2.1 Study design
We prospectively evaluated HRQOL in 60 patients admitted 
to the hospital (academic, regional referral centre with a 
24-hour interventional cardiology service) due to the first 
AMI and participating in the AFFECT EV Quality of Life 
Substudy (14). The study protocol, designed in compliance 
with the Declaration of Helsinki, was approved by the Ethics 
Committee of Medical University of Warsaw (approval 
number: KB/112/2016) and published previously (15).
2.2 Target populations and sampling
All participants provided written informed consent. Study 
inclusion and exclusion criteria are listed in Table 1. Patients 
were eligible for enrolment if they (i) were admitted 
to the hospital due to the first ST-segment elevation of 
acute myocardial infarction (STEMI) or non-STEMI (NSTEMI) 
qualified for early invasive revascularisation, and (ii) 
underwent percutaneous coronary intervention (PCI) 
with stent implantation. STEMI was diagnosed based on 
persistent ST-segment elevation of at least 0.1 mV in at 
least two contiguous electrocardiography leads or a new 
left bundle-branch block (16). NSTEMI was diagnosed as ST-
segment changes on ECG including ST depression, transient 
ST elevation and T-wave changes, along with a positive 
cardiac troponin test indicating myocardial necrosis in 
patients with the typical anginal chest pain (17).
2.3 Study population
Between January 2017 and June 2018, 60 patients were 
enrolled, and 56 patients were included in the final analysis 
(mean age 64.3±9.7 years, 75% male). The study flow chart 
is showed in Figure 1. Four patients did not attend the 
follow-up visit after 6 months and were excluded from the 
study.
• Age ≥ 18 years
• Informed consent to participate in the study
• First ST-elevation myocardial infarction (STEMI) or non-STEMI
• PCI with stent implantation
• Capability to fill-in the quality-of-life questionnaires 
alone or under supervision 
• Cardiogenic shock
• Severe chronic renal failure 
(eGFR<30 mL/min)
• Severe liver insufficiency 
(Child-Pugh C)
• Autoimmune disease
• Active neoplasm
• Known pregnancy, breast-feeding, or intention to 
become pregnant during the study period
Table 1. Eligibility criteria for the study evaluating the health-related quality of life after first-time acute myocardial infarction in Poland.
Legend: AMI – acute myocardial infarction; eGFR – estimated glomerular filtration rate; PCI – percutaneous coronary intervention
Exclusion criteriaInclusion criteria
10.2478/sjph-2022-0005 Zdr Varst. 2022;61(1):24-31
26
Figure 1. Study inclusion and exclusion chart. AMI – acute 
myocardial infarction.
2.4 Data collection procedure
Patients’ baseline and clinical data were extracted 
from medical records. Before discharge, patients 
underwent echocardiography. All patients received 
standard treatment after AMI according to the guidelines, 
depending on the individual clinical characteristics and 
comorbidities. All patients who qualified for a cardiac 
rehabilitation were involved in the rehabilitation program.
HRQOL was assessed during the index hospitalization 
and after 6 months using the following standardised 
questionnaires: (i) MacNew Heart Disease, (ii) World Health 
Organization Quality of Life (WHOQOL) BREF and (iii) Short 
Form (SF) 36 Health Survey. All questionnaires have been 
validated in the Polish population (11–13). The same two 
investigators (K.P. and A.Ć.) obtained questionnaire data 
during the index hospitalisation and follow-up.
The MacNew Heart Disease survey was designed to 
evaluate symptoms and well-being levels in patients 
with symptomatic coronary artery disease and with HF 
(18) after AMI. It consists of 27 questions grouped into 
3 domains: physical, mental, and social. In addition, the 
global HRQOL is calculated as the sum of points from the 
3 domains. The license was obtained from MacNewTM 
(Innsbruck, Austria).
The WHOQOL BREF evaluates general QOL and covers 4 
domains: physical health, psychological health, social 
relationships, and environmental stability (19). It consists 
of 26 items referring to energy and fatigue, mobility, 
self-esteem, social support, and financial resources. 
The questionnaire was obtained as a courtesy of the 
Prof. Krystyna Jaracz (Department of Neurological and 
Psychiatric Nursing, Poznan University of Medical Sciences, 
Poznan, Poland).
The SF-36 Health Survey consists of 36 questions grouped 
into 8 domains, including general health, physical 
functioning, limitations due to physical health problems, 
limitations due to emotional problems, bodily pain, 
vitality, social functioning, and mental health (20). The 
questionnaire was interpreted according to the Polish 
version developed by Prof. Jan Tylka (21). The license was 
obtained as a courtesy of Dr. Krzysztof Gąsecki (Chair of 
Social Pedagogy and Educational Research Methodology, 
Faculty of Social Sciences, University of Warmia and 
Mazury, Olsztyn, Poland).
2.5 Observed outcomes
The primary outcome was the change in the HRQOL 
between the index hospitalization and 6-month follow-up 
using the MacNew questionnaire, which was specifically 
designed to evaluate QOL in patients after AMI. The 
secondary outcomes were the changes in HRQOL from the 
index hospitalization to 6 months using the WHOQOL BREF 
and SF-36 questionnaires. Based on the literature, we 
defined an improvement in the HRQOL as an improvement 
between the index hospitalisation and follow-up of at least 
1 unit in the MacNew questionnaire and at least 10 units in 
the WHOQOL BREF and SF-36 questionnaires (22–24).
2.6 Explanatory factors
To determine the clinical variables which potentially 
affect HRQOL after AMI, we collected data regarding 
the following explanatory factors: demographics (age, 
gender), BMI, diagnosis at admission, cardiovascular 
risk factors (smoking, hypertension, dyslipidaemia, 
diabetes), laboratory parameters at admission (creatinine, 
haemoglobin level, low-density lipoprotein-cholesterol 
concentration, platelet count, troponin I concentration), 
left ventricle ejection fraction (LVEF) at admission, 
pharmacotherapy at discharge and attendance to cardiac 
rehabilitation.
2.7 Methods of analysis
The sample size was calculated by a two-sided t-test at a 
significance level of 0.05 using the following assumptions: 
(i) mean difference between the timepoints=1, (ii) 
standard deviation (SD) at the index hospitalisation and 
follow-up±1.5, and (iii) nominal test power=0.9. Based on 
this sample size estimation, a total of 49 patients should 
be enrolled in the study to observe a significant difference 
in the HRQOL between the index hospitalization and 
6-month follow-up. Taking into account that up to 20% 
of patients could be potentially lost during follow-up, 60 
patients were included in the study.
We conducted statistical analysis using IBM SPSS Statistics, 
version 27.0. Categorical variables were presented as 
numbers and percents. The Shapiro–Wilk test was used 
10.2478/sjph-2022-0005 Zdr Varst. 2022;61(1):24-31
27
to test for normal distribution of continuous variables. 
Continuous variables were presented as a mean and 
standard deviation, or as a median with inter-quartile 
range. Differences in quality of life between the two 
time points were assessed using the Wilcoxon signed rank 
test. Characteristics of patients with and without altered 
HRQOL after AMI in each of the three questionnaires were 
compared using the Mann–Whitney U test (continuous 
variables) and Chi-square test (categorical variables). The 
logistic regression model was performed manually (step-
by-step), where HRQOL was used as a dependent variable 
and variables, which significantly differed between patients 
with and without altered HRQOL at 6 months and which 
were predictors of improved HRQOL in univariate analysis 
were used as independent variables. The area under 
receiver operating characteristic (AUC under ROC) curve 
was used to determine the cut-off of continuous variables 
associated with altered HRQOL. Mortality and other adverse 
events were reported descriptively. For univariate analysis, 
a p-value below 0.1 was considered significant. For all other 
analyses, a p-value below 0.05 was considered significant.
3 RESULTS
3.1 Description of the study group
Patient characteristics are presented in Table 2. Of 
56 patients included in the analysis, 61% had arterial 
hypertension, 23% suffered from diabetes mellitus, 64% 
had dyslipidaemia and 52% were smokers. At admission, 
79% of patients were presented with STEMI. All patients 
had a successful PCI with at least 1 stent implantation. 
The median LVEF post-PCI was 52% (27-68%). All patients 
received dual antiplatelet therapy and statin and 
more than 90% of patients received a β-blocker and an 
angiotensin-converting enzyme inhibitor or an angiotensin 
receptor blocker. Until the 6-month follow-up, there were 
no deaths and no recurrent thrombotic events during the 
study, neither in STEMI nor in NSTEMI patients. 
Characteristic
Age, years – mean (SD)
Male gender – n (%)
BMI – n (range)
STEMI at admission – n (%)
LVEF, % – median (range)
CV risk factors – n (%)
   Arterial hypertension
   Diabetes mellitus
   Dyslipidaemia
   Smoking
Laboratory parameters
   Creatinine, mg/dl – median (range)
   Hb, g/dl – median (range)
   LDL-C – median (range)
   NT-proBNP – median (range)
   Plt count, 103/μl – median (range)
   TnI, ng/ml – median (range)
Pharmacotherapy at discharge – number (%)
   Aspirin
   P2Y12 inhibitor
   Statin
   β-blocker
   ACE-inhibitor or ARB
   Diuretics
   Aldosterone antagonists
Cardiac rehabilitation – number (%)
64.3
42
28.5
44
52
34
13
36
29
0.95
13.8
122
764
230
13.0
56
56
56
51
54
13
14
44
63.2
21
29.0
22
50
16
7
20
13
0.94
13.9
124
962
236
20.3
26
26
26
25
25
7
6
22
0.593
0.353
0.046
0.305
0.013
0.906
0.541
0.046
0.803
0.966
0.698
0.928
0.153
0.533
0.457
1.000
1.000
1.000
0.214
0.918
0.541
0.757
0.305
65.2
21
27.1
22
55
18
6
16
16
0.95
13.9
122
386
230
11.4
30
30
30
26
29
6
8
22
9.7
75%
20.3-30.2
79%
27-68
61%
23%
64%
52%
0.33-1.65
10.2-17.5
53-218
127-12708
111-453
0.4-685
100%
100%
100%
91%
96%
23%
25%
79%
8.6
80%
20.0-34.7
84%
27-58
0.62% 
27%
76%
50%
0.55-1.51
11.3-17.5
69-197
146-4942
131-352
0.5-685
100%
100%
100%
96%
96%
27%
23%
84%
10.7
70%
20.3-30.2
73%
35-68
60%
20%
53%
53%
0.33-1.65
10.2-16.0
65-218
127-12708
172-281
0.4-236
100%
100%
100%
87%
97%
20%
27%
73%
Table 2. Comparison of baseline characteristics between patients with improved and without improved health-related quality of life, 
as assessed by Short Form-36 Health Survey. P-value<0.05 is considered significant.
Legend: ACE: angiotensin-converting enzyme; ARB: angiotensin-receptor blockers; BMI: body mass index, weight in kilograms divided 
by square of the height in meters; CRP: C-reactive protein; Hb: haemoglobin; IQR: interquartile range; LDL-C: low-density lipoprotein-
cholesterol; LVEF: left ventricle ejection fraction; NSTEMI: non-ST-segment elevation myocardial infarction; NT-proBNP: N-terminal 
pro-b-type natriuretic peptide; Plt: platelets; SD: standard deviation; STEMI: ST-segment elevation myocardial infarction.
All patients
(n=56)
QoL improved
(n=26)
pQoL not improved
(n=30)
Inclusion criteria
10.2478/sjph-2022-0005 Zdr Varst. 2022;61(1):24-31
28
3.2 Observed outcomes
Figure 2 shows the changes in HRQOL between the index 
hospitalization and follow-up visit at 6 months. Whereas 
global, social, and physical functioning did not change 
(p≥0.063), whereas emotional functioning improved after 
AMI (p=0.002), as measured by the MacNew questionnaire. 
Physical health, psychological health, and environmental 
functioning did not change (p≥0.321), whereas social 
relationships improved after AMI (p=0.042), as measured 
by WHOQOL BREF. The global HRQOL improved after AMI 
(p=0.044), as assessed by SF-36.
Patients with improved HRQOL in SF-36 had a higher 
baseline BMI (p=0.046), often with dyslipidaemia (p=0.046) 
and lower LVEF at discharge (p=0.013), compared to 
patients without improved HRQOL in SF-36. There were 
no significant differences between the characteristics 
of patients with and without improved HRQOL after AMI 
when administering the MacNew (emotional functioning) 
and WHOQOL BREF (social relationships) surveys.
3.3 Results of univariate analysis
Table 3 shows the results of univariate analysis for 
prediction of improved HRQOL in SF-36 using explanatory 
factors. BMI, left ventricle EF<50% and dyslipidaemia 
predicted improved HRQOL at p<0.1 (odds ratio [OR] 5.094, 
95% confidence interval [CI] 0.987-1.269, p=0.080 for BMI; 
OR 5.863, 95% CI 1.441-23.851, p=0.013 for LVEF<50%; 
OR 2.917, 95% CI 0.914-9.309, p=0.071 for dyslipidaemia, 
respectively)
Figure 2. Changes in health-related quality of life from the index hospitalisation due to acute myocardial infarction up to a 6-month follow-
up assessed with three questionnaires in 56 patients.
The MacNew Heart Disease (Panel A), WHO Quality of Life-BREF (Panel B), and Short Form (SF) 36 Health Survey (panel C). Data are 
expressed as median and interquartile range and compared using Mann-Whitney U test. P-value<0.05 is considered significant.
3.4 Results of multivariate analysis
Table 4 shows the results of multivariate logistic regression 
including clinical variables which differed between patients 
with and without improved QOL in SF-36 and which were 
predictors of improved QOL in univariate analysis. EF was 
the only variable independently associated with improved 
QOL in multivariate analysis (OR 4.463, 95% CI 1.045 
- 19.059, p=0.043). The cut-off for EF associated with 
improved HRQOL determined based on the ROC curve was 
50% (AUC 0.70, CI 0.56-0.84, p=0.013).
4 DISCUSSION
The main finding of this study is that HRQOL increased 
6 months after the first AMI, especially in terms of 
emotional functioning and social relationships. We also 
found that patients with improved HRQOL in SF-36 had a 
higher baseline BMI, more often had dyslipidaemia, and 
more often had LVEF<50% compared to patients without 
improved HRQOL, indicating that patients with more 
comorbidities before AMI have a large chance for improved 
QOL after AMI. Finally, we showed that LVEF<50% was the 
only variable independently associated with improved 
HRQOL in multivariate analysis, increasing the odds of 
improved HRQOL 4.5-fold.
10.2478/sjph-2022-0005 Zdr Varst. 2022;61(1):24-31
29
Improved quality of life 6 months after an AMI is 
contradictory to the common view that AMI might 
decrease the quality of life, which has been found in 
previous studies (25–28). In line with our results, other 
authors also found that HRQOL improves one year after 
the first AMI in 587 patients, as assessed by SF-36 and 
Euro Quality of Life questionnaires (22). Similarly, a study 
comprising 534 patients showed gradual improvement in 
HRQOL up to 4 years after AMI, as assessed by Quality 
of Life after Myocardial Infarction questionnaire (23). 
Finally, a recent meta-analysis of 29 studies demonstrated 
a significant improvement of QOL in acute coronary 
syndrome patients regardless of the medical therapy 
administered (PCI, coronary artery bypass grafting and 
pharmacotherapy) (24). Altogether, QOL seems to improve 
in Polish patients after AMI, similar to patients from other 
European countries and the US.
Whereas in our study the HRQOL increased, especially in 
terms of emotional functioning and social relationships, 
most previous studies found an increase in the overall 
QOL (22–24). This discrepancy might be due to our study’s 
smaller sample sizes compared to previous studies, or 
the differences in sensitivity among the MacNew and 
WHOQOL BREF fields. It was postulated that the MacNew 
questionnaire is more likely to identify changes in the 
emotional field than in other domains (29). In addition, 
previous data showed that anxiety tends to decrease in 
the months following AMI, which might be due to the fact 
that patients start to cope with their diagnosis and adjust 
to the new situation (30). Although we had no specific 
questionnaire targeting anxiety, decreased anxiety likely 
contributes to the improved emotional and social aspects 
of QOL after AMI.
In our study, patients with improved HRQOL had a higher 
baseline BMI, often with dyslipidaemia and often with 
LVEF<50%. These findings might be explained by the fact 
that initially more morbid patients might undergo more 
intense ambulatory care for secondary prevention of 
CVD. However, in absence of reliable data to confirm this 
explanation, it remains a hypothesis. Also, data regarding 
the association between BMI/ dyslipidaemia and HRQOL 
are conflicting. Whereas some authors found a gradual 
decrease of QOL with increasing BMI (31), especially in 
women (32), others showed that the relationship between 
BMI and HRQOL is affected by gender and age (33). 
Noteworthy, in a study including 21,218 patients, it was 
found that class I obesity was associated with better HRQL 
scores, as assessed by SF-36, compared to underweight, 
normal weight, overweight, and class II obese patients, 
which has been termed the “obesity paradox” (34). 
Similarly, in some studies patients with dyslipidaemia 
tended to have a higher overall HRQOL, as assessed by SF-
36 (26), whereas other studies demonstrated lower QOL 
in dyslipidaemic patients due to increased rates of pain, 
discomfort, and depression (35).
Baseline characteristics
   Age, years 
   Gender 
   BMI
   STEMI at admission 
   LVEF<50%
CV risk factors
   Arterial hypertension
   Diabetes mellitus
   Dyslipidaemia
   Smoking
Laboratory parameters
   Creatinine
   Hb
   LDL-C
   NT-proBNP
   Plt count
   TnI
Pharmacotherapy at discharge 
   Aspirin
   P2Y12 inhibitor
   Statin
   β-blocker
   ACE-inhibitor or ARB
   Diuretics
   Aldosterone antagonists
Cardiac rehabilitation 
– number (%)
BMI
Dyslipidaemia
EF<50%
0.978
0.556
1.119
0.500
5.863
1.067
1.474
2.917
0.875
1.328
1.221
0.999
1.000
0.996
1.003
0.959
1.320 
0.998
3.846
0.862
1.474
0.825
1.010
1.096
1.921
4.463
0.925
0.159
0.987
0.131
1.441
0.364
0.424
0.914
0.306
0.150
0.799
0.984
1.000
0.988
0.996
0.867
0.833
0.990
0.402
0.051
0.424
0.244
0.986
0.958
0.544
1.045
1.033
1.938
1.269
1.905
23.851
3.128
5.121
9.309
2.504
11.771
1.865
1.013
1.000
1.005
1.010
 
1.014
2.093
1.006
36.822
14.506
5.121
2.793
1.034
1.255
6.786
19.059
0.424
0.356
0.080
0.310
0.013
0.906
0.542
0.071
0.803
0.799
0.356
0.873
0.976
0.389
0.425
0.593
0.238
0.551
0.243
0.918
0.542
0.757
0.432
0.180
0.310
0.043
Table 3.
Table 4.
Results of univariable logistic regression analysis for 
prediction of improved quality of life, as assessed 
by Short Form-36 Health Survey. P-value<0.1 is 
considered significant.
Results of multivariable logistic regression analysis 
for prediction of improved quality of life (QOL) 6 
months after AMI, as assessed by Short Form-36 
Health Survey, including explanatory factors which 
significantly differed between patients with and 
without improved QOL and which were predictors of 
improved QOL in univariate analysis.
Legend: BMI: body mass index, CI: confidence 
interval; EF: ejection fraction, OR: odds ratio.
OR
OR
95% CI
95% CI
Lower
Lower
Upper
Upper
p-value
p-value
Variable
Variable
10.2478/sjph-2022-0005 Zdr Varst. 2022;61(1):24-31
30
Finally, in our study LVEF<50% was the only independent 
predictor of improved HRQOL after AMI. Since LVEF<50% 
is a diagnostic criterion for HF with mid-range EF (40-49%) 
or HR with reduced (<40%) EF (36), it is likely that patients 
with LVEF<50% received more intensive medical therapy 
to improve their prognosis and reduce HF symptoms 
(37), which translated into better HRQOL (38, 39). In the 
absence of confirmatory data, this explanation remains a 
hypothesis.
4.1 Limitations
The main limitation of our study is its single-centre design, 
which might limit the generalizability of the results. Since 
our hospital is an academic, regional referral centre, our 
results might not be applicable to smaller centres without 
24-hour interventional cardiology services. Secondly, the 
small sample size might increase the risk of potential 
enrolment bias. Thirdly, the observational study design 
does not allow any conclusions to be drawn regarding 
causality when identifying the possible improvement or 
decline of HRQOL predictors over time. Moreover, the 
present study was a substudy of the AFFECT EV study (14), 
wherefore the inclusion and/or exclusion criteria may have 
influenced the results. Thus, the applicability of the results 
to a general post-AMI population remains limited. Although 
we sought to collect thorough clinical data, the information 
on accompanying psychiatric disorders was limited. In 
addition, the data regarding the changes in LVEF over time 
was not collected, which could have influenced the QOL. 
Also, the patients’ social networks, which were not taken 
into consideration, may have had an impact. Finally, our 
logistic regression model is based on only 56 patients and 
included 3 variables, which makes it hypothesis-generating. 
Altogether, the results should be interpreted with caution 
and re-evaluated in future studies.
4.2 Importance of the study and suggestions for future 
research 
The results showing improvement of QOL in Poland after AMI 
enable the cautious conclusion to be drawn that Poland’s 
interventional treatment and early implementation of 
cardiac rehabilitation results in similar effects among 
Polish patients after AMI, as observed in other European 
countries and the US (22–24). Our results exhibit a need for 
well-designed studies concerning the association between 
different clinical variables and QOL after MMI, as extant 
published studies provide inconsistent results. 
The optimistic observations regarding the increase in 
QOL are most probably attributable to the availability of 
24-hour interventional cardiology service. However, one 
should not forget the importance of providing first aid in 
a timely manner, which greatly influences the prognosis of 
the patient undergoing AMI, and consequently QOL post-
AMI (40). Therefore, even in presence of well-developed 
infrastructure and well-established algorithms in patients 
after AMI, large-scale education programmes are 
indispensable for further improving QOL after AMI (41).
5 CONCLUSIONS
Patients admitted to the reference cardiology centre in 
Poland due to their first AMI experienced an increase in 
HRQOL 6 months after AMI, especially in terms of emotional 
functioning and social relationships, confirming the recent 
trends demonstrated in other developed countries. 
CONFLICT OF INTEREST
The authors declare that no conflicts of interest exist.
FUNDING
The study was financed by Medical University of Warsaw.
ETHICAL APPROVAL
The study was approved by the Ethics Committee of Medical 
University of Warsaw (approval number: KB/112/2016).
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