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Comparable Performance of the Kansas City Cardiomyopathy Questionnaire in Patients With Heart Failure With Preserved and Reduced Ejection Fraction
Open accessAbstract
Background—: Despite the growing epidemic of heart failure with preserved ejection fraction (HFpEF), no valid measure of patients’ health status (symptoms, function, and quality of life) exists. We evaluated the Kansas City Cardiomyopathy Questionnaire (KCCQ), a validated measure of HF with reduced EF, in patients with HFpEF. Methods and Results—: Using a prospective HF registry, we dichotomized patients into HF with reduced EF (EF≤ 40) and HFpEF (EF≥50). The associations between New York Heart Association class, a commonly used criterion standard, and KCCQ Overall Summary and Total Symptom domains were evaluated using Spearman correlations and 2-way ANOVA with differences between patients with HF with reduced EF and HFpEF tested with interaction terms. Predictive validity of the KCCQ Overall Summary scores was assessed with Kaplan–Meier curves for death and all-cause hospitalization. Covariate adjustment was made using Cox proportional hazards models. Internal reliability was assessed with Cronbach’s α. Among 849 patients, 200 (24%) had HFpEF. KCCQ summary scores were strongly associated with New York Heart Association class in both patients with HFpEF ( r =−0.62; P <0.001) and HF with reduced EF ( r =−0.55; P =0.27 for interaction). One-year event-free rates by KCCQ category among patients with HFpEF were 0 to 25=13.8%, 26 to 50=59.1%, 51 to 75=73.8%, and 76 to 100=77.8% (log rank P <0.001), with no significant interaction by EF ( P =0.37). The KCCQ domains demonstrated high internal consistency among patients with HFpEF (Cronbach’s α=0.96 for overall summary and ≥0.69 in all subdomains). Conclusions—: Among patients with HFpEF, the KCCQ seems to be a valid and reliable measure of health status and offers excellent prognostic ability. Future studies should extend and replicate our findings, including the establishment of its responsiveness to clinical change.
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“The KCCQ is a standardized, 23-item, participant-administered instrument that quantifies heart failurerelated symptoms (frequency, severity, and recent changes), physical function, quality of life, and social function. 16-18 For each domain, the validity, reproducibility, responsiveness, and interpretability have been independently established. 16-18”
From Semaglutide in Patients with Heart Failure with Preserved Ejection Fraction and Obesity (2023) · cites this paper as [17]
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Statistics notes: Cronbach's alpha: Table 1
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BackgroundInfluentialHeart failure with preserved left ventricular systolic function
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Semaglutide in Patients with Heart Failure with Preserved Ejection Fraction and Obesity
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Self-citationDevelopment and validation of a short version of the Kansas City Cardiomyopathy Questionnaire
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Self-citationUtility of patient-reported outcome instruments in heart failure
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Self-citationHealth-Related Quality of Life in Heart Failure With Preserved Ejection Fraction
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Self-citationRate-Adaptive Atrial Pacing for Heart Failure With Preserved Ejection Fraction
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Self-citationHeart Failure With Preserved Ejection Fraction in the Young
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“Future studies should extend and replicate our findings, including the establishment of its responsiveness to clinical change.(17)”
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Self-citationOverview of the socio-economic consequences of heart failure
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“Another study with the disease-specific Kansas City Cardiomyopathy Questionnaire (KCCQ) found no significant difference between HF patients with an ejection fraction lower than 40 or higher than 50 (23).”
MethodLeft Atrial Decompression Pump for Severe Heart Failure With Preserved Ejection Fraction
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Self-citationUse of Patient-Reported Outcomes in Heart Failure: From Clinical Trials to Routine Practice
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“(2–4) Patients with HF and preserved ejection fraction (HFpEF), who now comprise half of all patients with HF,(5) struggle with poor HRQOL similar to patients with HF and reduced ejection fraction (HFrEF).(6) Improving HRQOL remains a primary goal in the management of patients with HFpEF(7), and is reliant upon the ab…”
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“Most were validated employing HF patients with reduced left ventricular ejection fraction, however the Kansas City Cardiomyopathy Questionnaire (KCCQ) was also tested in patients with preserved left ventricular ejection fraction and advanced HF (17,18).”
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“SEE PAGE 226 A n increasing number of patients have heart failure with preserved ejection fraction (HFpEF) (1), leading to hospitalizations and decreased quality of life (2).”
BackgroundLuo, N., Teng, T. K., Tay, W. T., Anand, I. S., Kraus, W. E., Liew, H. B., Ling, L. H., O’Connor, C. M., Piña, I. L., Richards, M., et al. (2017) · American Heart Journal · doi:10.1016/j.ahj.2017.06.016 · Cited by 45
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“bKansas city cardiomyopathy Questionnaire (overall summary scale) (green et al. 2000; Joseph et al. 2013).”
Rationale and Design of the VITALITY-HFpEF Trial
Butler, J., Lam, C. S. P., Anstrom, K. J., Ezekowitz, J. A., Hernandez, A. F., O’Connor, C. M., Pieske, B. M., Ponikowski, P. P., Shah, S. J., Solomon, S. D., et al. (2019) · Circulation Heart Failure · doi:10.1161/circheartfailure.119.005998 · Cited by 44
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“Elevated NT-proBNP levels at randomization (cut-offs >220 pg/mL in patients with no atrial fibrillation or atrial flutter (nonAF), and > 600 pg/mL in patients with ongoing AF reinforces the diagnosis of HFpEF.”
MethodInfluentialQuality of life and outcomes in heart failure patients with ejection fractions in different ranges
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Extended‐Release Oral Milrinone for the Treatment of Heart Failure With Preserved Ejection Fraction
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Minimally Clinically Important Difference in Health Status Scores in Patients With HFrEF vs HFpEF
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Automated E-Counseling for Chronic Heart Failure
Nolan, R. P., Ross, H. J., Farkouh, M. E., Huszti, E., Chan, S., Toma, M., D’Antono, B., White, M., Thomas, S. G., Barr, S. I., et al. (2021) · Circulation Heart Failure · doi:10.1161/circheartfailure.120.007073 · Cited by 30
Alonso, W., Kupzyk, K. A., NORMAN, J. F., Lundgren, S. W., Fisher, A. L., Lindsey, M. L., Keteyian, S. J., & Pozehl, B. (2021) · Journal of Cardiac Failure · doi:10.1016/j.cardfail.2021.09.003 · Cited by 35
“To date, 1 shorter term (20 weeks) study6 and 1 longer term (12 months) study, OptimexClin10 have used the KCCQ to test exercise effects on health status in HFpEF.”
MethodInfluentialDesai, N. R., Olewińska, E., Famulska, A., Rémuzat, C., François, C., & Folkerts, K. (2024) · Heart Failure Reviews · doi:10.1007/s10741-024-10385-y · Cited by 36
“In a study by Joseph (2013), NYHA class correlated with KCCQ scores in both HFpEF and HFmrEF groups, suggesting that HRQoL could be related to factors other than EF, such as symptom severity [96].”
BackgroundMethodInfluentialAssociations Between Depressive Symptoms and HFpEF-Related Outcomes
Chandra, A., Alcalá, M. A. D., Claggett, B. L., Desai, A. S., Fang, J. C.-T., Heitner, J. F., Liu, J., Pitt, B., Solomon, S. D., Pfeffer, M. A., et al. (2020) · JACC Heart Failure · doi:10.1016/j.jchf.2020.06.010 · Cited by 29
Ivynian, S. E., Ferguson, C., Newton, P. J., & DiGiacomo, M. L. (2020) · International Journal of Nursing Studies · doi:10.1016/j.ijnurstu.2020.103603 · Cited by 28
Xhakollari, L., GRUBB, A. O., Jujić, A., Bachus, E., Nilsson, P. M., Leósdóttir, M., Christensson, A. G., & Magnusson, M. (2021) · ESC Heart Failure · doi:10.1002/ehf2.13485 · Cited by 28
Medication management strategies used by older adults with heart failure: A systems-based analysis
Mickelson, R. S., & Holden, R. J. (2017) · European Journal of Cardiovascular Nursing · doi:10.1177/1474515117730704 · Cited by 26
Implantable Cardioverter–Defibrillator Use in Older Adults
Kramer, D. B., Matlock, D. D., Buxton, A. E., Goldstein, N. E., Goodwin, C., Green, A. R., Kirkpatrick, J. N., Knoepke, C. E., Lampert, R. J., Mueller, P. S., et al. (2015) · Circulation Cardiovascular Quality and Outcomes · doi:10.1161/circoutcomes.114.001660 · Cited by 26
Self-citationValidation of the Kansas City Cardiomyopathy Questionnaire in Patients With Tricuspid Regurgitation
Arnold, S. V., Spertus, J. A., GOSCH, K. L., Dunlay, S. M., Olds, D. M., Jones, P. G., Bocell, F. D., Wu, C., & Cohen, D. J. (2024) · JAMA Cardiology · doi:10.1001/jamacardio.2024.4266 · Cited by 26
Self-citationA Home-Based Diaphragmatic Breathing Retraining in Rural Patients With Heart Failure
Seo, Y., Yates, B. C., LaFramboise, L. M., Pozehl, B., NORMAN, J. F., & Hertzog, M. A. (2015) · Western Journal of Nursing Research · doi:10.1177/0193945915584201 · Cited by 28
“Reliability and validity of the KCCQ was well established: Cronbach’s alpha for the symptom domain of the KCCQ was .89; validity evidence was provided by a correlation of −.55 between KCCQ overall summary scores and NYHA functional class in HF patients (Green et al., 2000; Joseph et al., 2013).”
BackgroundMethodBhatt, A. S., Kosiborod, M., Vaduganathan, M., Claggett, B. L., Miao, Z. M., Kulac, I. J., Lam, C. S. P., Hernandez, A. F., Martínez, F. A., Inzucchi, S. E., et al. (2023) · European Journal of Heart Failure · doi:10.1002/ejhf.2909 · Cited by 24
Mendoza, V. L., Tumanan-Mendoza, B. A., & Punzalan, F. E. R. (2021) · ESC Heart Failure · doi:10.1002/ehf2.13583 · Cited by 22
“KCCQ scores were found to correlate with the New York Heart Association (NYHA) Functional Class, whether among patients with HFrEF or HF with preserved ejection fraction (HFpEF).(20) In turn, utility estimates had been derived for each of the NYHA class.”
MethodShah, S. J., Bonderman, D., Borlaug, B. A., Cleland, J. G. F., Lack, G., Lu, W., Voors, A. A., Zannad, F. M., & Gladwin, M. T. (2025) · Circulation Heart Failure · doi:10.1161/circheartfailure.123.011381 · Cited by 21
Shah, S. J., Cowie, M., Wachter, R., Szecsödy, P., Shi, V. C., Ibram, G., Hu, M., Zhao, Z., Gong, J., & Pieske, B. M. (2021) · European Journal of Heart Failure · doi:10.1002/ejhf.2277 · Cited by 22
A cultural and gender-based approach to understanding patient adjustment to chronic heart failure
Surikova, J., Payne, A. Y. M., Miller, K., Ravaei, A., & Nolan, R. P. (2020) · Health and Quality of Life Outcomes · doi:10.1186/s12955-020-01482-1 · Cited by 20
New York Heart Association Class and Kansas City Cardiomyopathy Questionnaire in Acute Heart Failure
Huo, X., Pu, B., Wang, W., Peng, Y., Li, J., Lei, L., Zhang, L., & Li, J. (2023) · JAMA Network Open · doi:10.1001/jamanetworkopen.2023.39458 · Cited by 20
Cresci, S., Bach, R. G., Saberi, S., OWENS, A. T., Spertus, J. A., Hegde, S. M., Lakdawala, N. K., Nilles, E. K., WOJDYLA, D. M., Sehnert, A. J., et al. (2023) · Circulation · doi:10.1161/circulationaha.123.065600 · Cited by 20
Self-citationMetra, M., Radulescu, C.-I., Cersosimo, A., Massussi, M., Laurito, A., Chioncel, O., & Adamo, M. (2024) · Journal of Cardiovascular Medicine · doi:10.2459/jcm.0000000000001591 · Cited by 20
Cosiano, M. F., Vista, A., Sun, J., Alhanti, B., Harrington, J., Butler, J., Starling, R. C., Mentz, R. J., & Greene, S. J. (2022) · Circulation Heart Failure · doi:10.1161/circheartfailure.122.010107 · Cited by 19
Hejjaji, V., Tang, Y., Coles, T., Jones, P. G., Reeve, B. B., Mentz, R. J., Spatz, E. S., Dunlay, S. M., Caldwell, B., Saha, A., et al. (2021) · Circulation Heart Failure · doi:10.1161/circheartfailure.120.008284 · Cited by 18
Self-citationProtocol-based follow-up program for heart failure patients: Impact on prognosis and quality of life
Agostinho, J. R., Gonçalves, I. S., Rigueira, J., Aguiar-Ricardo, I., Nunes-Ferreira, A., Santos, R., Guimarães, T., Alves, P. B., Cunha, N., Rodrigues, T., et al. (2019) · Revista Portuguesa de Cardiologia · doi:10.1016/j.repc.2019.03.006 · Cited by 18
Butler, J., Spertus, J. A., Bamber, L., Khan, M. S., Roessig, L., Vlajnic, V., Norquist, J. M., Anstrom, K. J., Blaustein, R. O., Lam, C. S. P., et al. (2022) · European Journal of Heart Failure · doi:10.1002/ejhf.2481 · Cited by 18
Self-citationPatient-Reported Outcomes in Patients with Cardiomyopathy
Garcia, R. A., Benton, M. C., & Spertus, J. A. (2021) · Current Cardiology Reports · doi:10.1007/s11886-021-01511-5 · Cited by 17
Self-citationPrevalence and Prognostic Significance of Frailty in Asian Patients With Heart Failure
Aung, T., Qin, Y., Tay, W. T., Bamadhaj, S., Chandramouli, C., Ouwerkerk, W., Tromp, J., Anand, I. S., Richards, M., Hung, C., et al. (2021) · JACC Asia · doi:10.1016/j.jacasi.2021.09.006 · Cited by 17
“The assessment of health-related quality of life in patients with HF was measured using the Kansas City Cardiomyopathy Questionnaire (KCCQ), a 23-item self-administered HF-specific questionnaire validated in multiple HF-related disease states (22-24).”
MethodArnold, S. V., Manandhar, P., Vemulapalli, S., Vekstein, A. M., Kosinski, A. S., Spertus, J. A., & Cohen, D. J. (2021) · European Heart Journal - Quality of Care and Clinical Outcomes · doi:10.1093/ehjqcco/qcab078 · Cited by 16
Self-citationEffect of Dietary Sodium Restriction on the Quality of Life of Patients With Heart Failure
Zhu, C., Cheng, M., Su, Y., Ma, T., Lei, X., & Hou, Y. (2021) · The Journal of Cardiovascular Nursing · doi:10.1097/jcn.0000000000000880 · Cited by 16
“This may reduce the suffering of patients from adherence to sodium restriction and even allow them to have a better QoL.”
BackgroundInfluentialHealth-Related Quality of Life in Left Ventricular Assist Device-Supported Patients
Zadok, O. I. B., Ben‐Avraham, B., Jaarsma, T., Shaul, A. A., Hammer, Y., Barac, Y. D., Mats, I., Eldar, O., Abuhazira, M., Yaari, V., et al. (2021) · ESC Heart Failure · doi:10.1002/ehf2.13282 · Cited by 16
“Patients with HF with reduced ejection fraction in New York Heart Association Class IV were reported to have a mean KCCQ summary score of 29, 15 much lower than our LVAD-supported patients.”
Predictive value of quality of life as measured by KCCQ in heart failure patients: A meta‐analysis
Kao, G., Xú, G., Zhang, Y., Li, C., & Xiao, J. (2024) · European Journal of Clinical Investigation · doi:10.1111/eci.14233 · Cited by 15
“37 Patients with higher NYHA class are typically associated with lower KCCQ scores, suggesting that their health-related QoL may be more severely impacted.”
Huang, W., Teng, T. K., Tay, W. T., Richards, M., Kadam, U. T., Lawson, C. A., Shimizu, W., Loh, S. Y., Anand, I. S., & Lam, C. S. P. (2020) · ESC Heart Failure · doi:10.1002/ehf2.12950 · Cited by 15
“Our results are also congruent with previous reports on the association of KCCQ clinical summary score and clinical outcomes in patients with HF including those with HFpEF.(10,24) This study is limited in that, unlike some previous reports, it does not contain repeat data to assess for recall and intra‐class correlati…”
MethodResultLuiso, D., Herrero-Torrus, M., Badosa, N., Roqueta, C., Ruiz, S., Tornero, L. C. B., Moré, S. V., Murillo, R. O. M., Vázquez‐Ibar, O., & Farré, N. (2022) · Journal of Clinical Medicine · doi:10.3390/jcm11113035 · Cited by 14
“It has been validated in HF both with reduced and preserved ejection fractions [8,26].”
Barnard-Kelly, K. D., Battelino, T., Brosius, F. C., Ceriello, A., Cosentino, F., Gavin, J. R., Giorgino, F., Green, J., Ji, L., Kellerer, M., et al. (2025) · Cardiovascular Diabetology · doi:10.1186/s12933-024-02550-2 · Cited by 15
Flint, K. M., Shah, S. J., Lewis, E. F., & Kao, D. P. (2020) · ESC Heart Failure · doi:10.1002/ehf2.12660 · Cited by 14
“The KCCQ is also predictive of death and hospitalization in HFpEF patients.(18) KCCQ was collected at baseline, 4, 12, 24, 36, and 48 months.”
BackgroundMethodInfluentialHallinen, T., Kivelä, S., Soini, E. J., Harjola, V., & Pesonen, M. (2023) · ClinicoEconomics and Outcomes Research · doi:10.2147/ceor.s391455 · Cited by 14
Fumagalli, C., Ponti, L., Smorti, M., Pozza, F., Argirò, A., Zampieri, M., Mario, C. D., Marfella, R., Sardu, C., Paolisso, G., et al. (2024) · Aging Clinical and Experimental Research · doi:10.1007/s40520-024-02750-6 · Cited by 13
“…of severity of heart failure symptoms (i.e. NYHA Class) with worsening levels of patient reported outcomes (PROMS) such as KCCQ and European Quality of Life 5 Dimensions 5 Level Version (EQ-5D-5L) [24]; interestingly, other variables, including instrumental assessment, were not correlated.”
MethodAssessment of patient-reported outcomes measures in heart failure: a systematic review
Mendes, J. L., dos Santos, C. M., & Sousa‐Pinto, B. (2024) · Heart Failure Reviews · doi:10.1007/s10741-024-10404-y · Cited by 13
“In one, Cronbach’s alpha was higher than 0.95, and in the other, it was 0.60 for the self-efficacy subscale [48, 74].”
InfluentialVerinurad Plus Allopurinol for Heart Failure With Preserved Ejection Fraction
Kitzman, D. W., Voors, A. A., Mentz, R. J., Lewis, G. D., Perl, S., Myte, R., Kaguthi, G., Sjöström, C. D., Källgren, C., & Shah, S. J. (2024) · JAMA Cardiology · doi:10.1001/jamacardio.2024.2435 · Cited by 13
Interpreting Population Mean Treatment Effects in the Kansas City Cardiomyopathy Questionnaire
Jawad, M. A., Jones, P. G., Arnold, S. V., Cohen, D. J., Sherrod, C., Khan, M. S., Ikemura, N., Chan, P. S.-F., & Spertus, J. A. (2024) · JAMA Cardiology · doi:10.1001/jamacardio.2024.4470 · Cited by 13
Self-citationMcGregor, A. J., Peacock, W. F., Chang, A. M., Safdar, B., & Diercks, D. B. (2014) · Academic Emergency Medicine · doi:10.1111/acem.12526 · Cited by 13
Clinical Validation of Novel Digital Measures: Statistical Methods for Reliability Evaluation
Ratitch, B., Trigg, A., Majumder, M., Vlajnic, V., Rethemeier, N., & Nkulikiyinka, R. (2023) · Digital Biomarkers · doi:10.1159/000531054 · Cited by 14
Call for a Disease-Specific Patient-Reported Outcome Tool in Adult Congenital Heart Disease
Cedars, A. M., & Spertus, J. A. (2014) · Circulation Cardiovascular Quality and Outcomes · doi:10.1161/circoutcomes.114.001406 · Cited by 12
Self-citationStockdill, M. L., Dionne-Odom, J. N., Wells, R., Ejem, D., Azuero, A., Keebler, K., Sockwell, E., Tims, S., Burgio, K. L., Engler, S., et al. (2023) · Journal of Palliative Care · doi:10.1177/0825859720975978 · Cited by 11
“The Kansas City Cardiomyopathy Questionnaire(28) score ranges from 0-100 with higher scores indicating better perceived health status; clinical summary scores 50 are considered ‘‘fairly good’’ QOL(36,37) and a change of 5 points is considered a clinically important difference.(38,39) The FACITPAL 14(29) is scored from…”
Background
Metadata
- Authors
- Joseph, S. M., Novak, E., Arnold, S. V., Jones, P. G., Khattak, H., Platts, A. E., Dávila-Román, V. G., Mann, D. L., & Spertus, J. A.
- Affiliations
- Washington University in St. Louis (US)
- From the Cardiovascular Division, Department of Medicine, Washington University School of Medicine, St Louis, MO (S.M.J., E.N., H.K., A.E.P., V.G.D.-R., D.L.M.); and Saint Luke’s Mid-America Heart Institute, University of Missouri, Kansas City (S.V.A., P.G.J., J.A.S.).
- Venue
- Circulation: Heart Failure
- Published
- 2013-11
- Volume
- 6
- Issue
- 6
- Pages
- 1139-1146
- ISSN
- 1941-3289 (ISSN-L)
- 1941-3297
- PMC
- PMC4545244
- OpenAlex
- W2547126679
- Cited by
- 192
- References
- 50
- Citations by year
- 2026: 12 · 2025: 18 · 2024: 28 · 2023: 24 · 2022: 16 · 2021: 24 · 2020: 20 · 2019: 13 · 2018: 10 · 2017: 11 · 2016: 6 · 2015: 7 · 2014: 3
- FWCI
- 3.63
- Type
- journal article
- Language
- en
- Open access
- green
- www.ncbi.nlm.nih.gov
- Locations
- Circulation Heart Failure (publishedVersion)
- PubMed (publishedVersion)
- Europe PMC (PubMed Central) (acceptedVersion)
- PubMed Central (acceptedVersion)
- Adelaide Research & Scholarship (AR&S) (University of Adelaide) (submittedVersion)
- Funders
- National Heart, Lung, and Blood Institute (U10HL110309, RC2HL102222)
- Topics
- Health Sciences › Medicine › Cardiology and Cardiovascular Medicine › Heart Failure Treatment and Management
- Health Sciences › Medicine › Cardiology and Cardiovascular Medicine › Cardiovascular Function and Risk Factors
- Health Sciences › Medicine › Cardiology and Cardiovascular Medicine › Heart rate and cardiovascular health
- Keywords
- Kansas City Cardiomyopathy Questionnaire, heart failure with preserved ejection fraction, heart failure with reduced ejection fraction, health status measurement, quality of life, symptom burden, NYHA functional class, prognostic validity, mortality, hospitalization, internal consistency
- MeSH terms
- Female, Follow-Up Studies, Health Status, Heart Failure, Humans, Male, Middle Aged, Prognosis, Prospective Studies, Quality of Life, Surveys and Questionnaires, Severity of Illness Index, Stroke Volume, United States, Reproducibility of Results, Incidence, Disease Progression
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