Quality of Life in Heart Patients / Quality of Life after Myocardial Infarction Questionnaire

1. Abstract

The Quality of Life in Heart Patients Questionnaire (in Dutch: Kwaliteit van Leven bij Hartpatiënten, abbreviated as KvL-H), derived directly from and internationally recognized as the modified Quality of Life after Myocardial Infarction questionnaire (QLMI-2) and subsequently standardized as the MacNew Heart Disease Health-Related Quality of Life Questionnaire, is a disease-specific self-report psychometric instrument designed to evaluate health-related quality of life (HRQL) in individuals recovering from acute coronary syndromes, myocardial infarction, angina pectoris, and heart failure, or undergoing cardiac rehabilitation. Originating from the seminal interviewer-administered 26-item QLMI developed by Neil Oldridge and colleagues in 1991, the instrument underwent significant psychometric refinement into a 27-item self-administered version that assesses three core, interconnected domains of functioning: Emotional, Physical, and Social. In 2000, Thea van Elderen and colleagues validated the standardized 27-item Dutch adaptation (KvL-H), demonstrating high linguistic fidelity, robust structural validity, and profound sensitivity to clinical improvements occurring over the course of comprehensive multidisciplinary cardiac rehabilitation programs.

Each of the 27 items is scored on a standardized 7-point Likert-type response scale ranging from 1 (representing the poorest health-related quality of life, greatest limitation, or persistent distress) to 7 (representing optimal health-related quality of life, absence of symptoms, or unrestricted functioning), referencing an explicit recall window of the past two weeks. The instrument generates three domain-specific subscale scores alongside a global, overall HRQL composite score, calculated as the arithmetic mean of valid responses. Multiple psychometric investigations across international cohorts confirm that the scale possesses exceptional internal consistency reliability (Cronbach’s alpha coefficients routinely exceeding .90 for the total score and ranging from .86 to .93 across domain subscales) and strong test-retest reliability (intraclass correlation coefficients generally between .75 and .95). Construct, convergent, and discriminant validity have been demonstrated through substantial correlations with generic health status measures (such as the Medical Outcomes Study 36-Item Short-Form Health Survey [SF-36]), affective symptom inventories (including the Hospital Anxiety and Depression Scale [HADS]), and functional exercise metrics. With demonstrated evaluative sensitivity, low respondent burden, and an established minimal important difference (MID) of 0.50 points on the 7-point scale, the KvL-H/MacNew stands as a gold standard in cardiovascular behavioral medicine and clinical outcome research.

2. Keywords

Quality of Life after Myocardial Infarction, Kwaliteit van Leven bij Hartpatiënten, KvL-H, MacNew Heart Disease Questionnaire, Health-Related Quality of Life, Cardiac Rehabilitation, Coronary Artery Disease, Myocardial Infarction, Psychometrics, Patient-Reported Outcome Measures, Emotional Functioning, Physical Functioning, Social Functioning, Cardiovascular Behavioral Medicine

3. Authors

The developmental trajectory of this instrument reflects an extensive international and cross-cultural psychometric collaboration spanning North America and Europe over more than three decades:

• Neil B. Oldridge, Ph.D., FACSM: Professor of Medicine and Health Sciences, School of Medicine, University of Wisconsin-Milwaukee, and Aurora Cardiovascular Services, Milwaukee, Wisconsin, USA. Dr. Oldridge served as the primary investigator who conceptualized the original Quality of Life after Myocardial Infarction (QLMI) questionnaire in 1991 and spearheaded its subsequent structural updates.
• Gordon H. Guyatt, M.D., M.Sc.: Distinguished Professor, Department of Health Research Methods, Evidence, and Impact (HEI), McMaster University, Hamilton, Ontario, Canada. A foundational pioneer in evidence-based medicine and health-related quality of life methodology, Dr. Guyatt co-developed the initial item taxonomy and evaluative responsiveness criteria for the QLMI.
• Norman L. Jones, M.D., FRCP: Professor Emeritus of Medicine, Division of Respirology and Cardiology, McMaster University, Hamilton, Ontario, Canada. Contributed critically to cardiopulmonary exercise testing integration and physiological outcome validation within the instrument’s item architecture.
• David Feeny, Ph.D.: Health economist and psychometrician, Department of Economics, McMaster University, and Institute of Health Economics, Edmonton, Alberta, Canada. Contributed to utility assessment and structural measurement frameworks.
• Stefan Höfer, Ph.D.: Associate Professor, Department of Medical Psychology, Medical University of Innsbruck, Innsbruck, Austria. Led extensive pan-European cross-cultural validation trials and standardized the multi-language psychometric equivalence of the 27-item MacNew.
• Christoph R. Saner, M.D., and Collaborators: Involved in early psychometric iterations bridging the QLMI to the MacNew / QLMI-2 structural revision in 1996.
• Thea van Elderen, Ph.D.: Department of Clinical and Health Psychology, Leiden University, Leiden, The Netherlands. Lead investigator responsible for the Dutch cultural adaptation, translation, and comprehensive psychometric validation of the 27-item instrument, officially designated in the Dutch healthcare ecosystem as the Kwaliteit van Leven bij Hartpatiënten (KvL-H) in 2000.
• Stan Maes, Ph.D.: Professor of Health Psychology, Leiden University, Leiden, The Netherlands. Co-investigator on the Dutch cardiac rehabilitation longitudinal validation studies establishing the structural, predictive, and evaluative characteristics of the KvL-H.

4. Purpose

The primary clinical and scientific purpose of the Quality of Life in Heart Patients Questionnaire (KvL-H) / Quality of Life after Myocardial Infarction Questionnaire (MacNew/QLMI-2) is to systematically capture, quantify, and track the personal, functional, and psychological consequences of ischemic heart disease from the patient’s subjective perspective. Cardiovascular diseases—most notably myocardial infarction (MI), stable and unstable angina pectoris, and congestive heart failure—induce profound disruptions in daily functional capacity, vocational trajectory, interpersonal relationships, and psychological stability. While conventional clinical cardiovascular endpoints such as left ventricular ejection fraction, treadmill exercise tolerance, patency of revascularized coronary arteries, and mortality rates yield critical prognostic information, they demonstrate notoriously weak correlations with how patients genuinely feel and function on a day-to-day basis.

Consequently, the KvL-H serves as an essential patient-reported outcome measure (PROM) engineered specifically to assess the subjective efficacy of medical therapies, revascularization procedures (such as percutaneous coronary intervention [PCI] and coronary artery bypass grafting [CABG]), and structured multidisciplinary cardiac rehabilitation programs. The theoretical rationale rests upon the premise that true clinical recovery must encompass not merely the restoration of myocardial perfusion or hemodynamic stability, but the remediation of disease-induced emotional distress, restoration of physical independence, and resumption of meaningful social roles.

In routine clinical practice, the KvL-H functions as both a diagnostic screen and an evaluative progress monitor. Administered prior to commencing cardiac rehabilitation, baseline subscale profiles illuminate latent psychological vulnerability (e.g., severe demoralization, catastrophic fear of exertion, perceived worthlessness) or severe physical limitations that might otherwise escape routine physiological screening. Clinicians can utilize these domain profiles to tailor rehabilitation trajectories, directing highly anxious patients toward cognitive-behavioral stress management while routing functionally restricted patients toward targeted physiological conditioning. Administered longitudinally across mid-program, discharge, and multi-month follow-up intervals, the instrument tracks incremental recovery, flags failed adaptation or emergent depressive relapses, and demonstrates objective programmatic value to healthcare quality accreditation systems and third-party reimbursement agencies.

In empirical clinical research, the instrument provides an evaluative outcome measure possessing heightened responsiveness compared to generic health status profiles. Because generic tools like the SF-36 or EuroQol-5D contain items insensitive to cardiopulmonary symptomatology or framed too broadly to reflect acute cardiac improvements, they frequently fail to register meaningful changes observed following cardiac rehabilitation. The KvL-H/MacNew resolves this by embedding disease-salient phenomena—such as cardiac-specific chest discomfort, exertional dyspnea, fear of dying, loss of sexual confidence, and functional dependence—into an efficient, patient-centered framework.

5. Psychological Construct

The psychological and functional construct measured by the KvL-H is disease-specific Health-Related Quality of Life (HRQL) in cardiac patients. In psychometric terms, HRQL is conceptualized as a multidimensional, subjective, and dynamic appraisal of personal well-being that reflects how an ongoing pathological state and its associated therapeutic interventions influence a patient’s capacity to lead a fulfilling life. The KvL-H operationalizes this overarching construct through three interrelated, empirically derived domains: the Emotional Domain, the Physical Domain, and the Social Domain. Importantly, consistent with the multifaceted reality of chronic illness, several items within the 27-item architecture load simultaneously onto more than one domain, reflecting clinical and psychometric cross-domain interdependence.

5.1. The Emotional Domain

Comprising 14 items (Items 1, 2, 3, 4, 5, 6, 7, 8, 10, 11, 13, 15, 18, and 23), the Emotional subscale captures the profound psychological turbulence triggered by acute cardiac crises and chronic coronary artery disease. Following an acute cardiac event such as an infarction, individuals frequently experience what cardiology literature characterizes as “existential vulnerability” or “cardiac invalidism.” Patients grapple with sudden confrontations with mortality, unpredictable symptomatology, and an abrupt perceived loss of autonomy. This domain assesses:

• Affective Distress and Dysphoria: Measures the presence of demoralization, chronic frustration, unprovoked anger, depressive symptoms (“down in the dumps”), and emotional lability or tearfulness (Items 1, 7, 15).
• Self-Efficacy and Perceived Mastery: Evaluates the restoration of personal agency, internal locus of control, and confidence in one’s capacity to manage and cope with a chronic cardiac condition (Items 3, 10).
• Somatic Anxiety and Fear: Quantifies hypervigilant autonomic arousal, persistent apprehension, panic states, restlessness, and terror concerning recurrent infarction or sudden death (Items 13, 18).
• Self-Worth and Perceived Burden: Probes deep psychological disruptions wherein patients perceive themselves as inadequate, useless, or an intolerable burden on family members and societal networks (Items 2, 8).
• Vitality and Relaxation: Captures positive psychological functioning, including enthusiastic engagement with life, subjective energy, and the psychological capacity to achieve restorative relaxation devoid of internal muscular and cognitive tension (Items 4, 5, 11).

5.2. The Physical Domain

Comprising 13 items (Items 6, 9, 12, 14, 16, 17, 19, 20, 21, 24, 25, 26, and 27), the Physical subscale quantifies the direct physiological impingement of cardiac pathology on bodily integrity, physiological reserve, and routine daily motor performance. Rather than measuring objective cardiopulmonary parameters in a clinical vacuum, this subscale assesses the experiential burden of cardiovascular symptoms during routine physical living:

• Symptomatic Distress: Assesses the subjective frequency and disruption caused by hallmark coronary symptoms, specifically exertional or rest dyspnea (Item 6), typical angina pectoris or ischemic chest pain (Item 9), and hemodynamic instability manifesting as postural dizziness, lightheadedness, or presyncope (Item 12).
• Basic Locomotor Limitations: Measures restrictions encountered during fundamental ambulatory movements, such as walking on level ground at an ordinary pace (Item 20).
• Vigorous and Instrumental Exertion: Assesses functional limitations during higher-demand physical activities critical to independent living, including climbing flights of stairs, walking uphill, and lifting or carrying heavy household groceries (Item 16).
• Vitality and Physical Endurance: Captures systemic exhaustion, exertional fatigue, and whether the respondent possesses sufficient somatic energy reserves to navigate standard daily tasks without premature fatigue (Items 11, 19).
• Functional and Occupational Interference: Explores the degree to which physical restrictions disrupt usual vocational duties, household chores, and preferred personal recreational hobbies (Items 14, 24).

5.3. The Social Domain

Comprising 7 items (Items 17, 21, 22, 23, 24, 25, and 26), the Social subscale evaluates the transactional friction between the cardiac patient and their interpersonal environment. Chronic illness invariably reshapes family dynamics, creates dependency, disrupts vocational roles, and destabilizes intimacy. This domain explores:

• Interpersonal and Familial Dynamics: Gauges the extent to which the cardiac condition creates strain, role reversals, or friction within the primary domestic family unit (Item 22).
• Social Participation and Community Life: Measures restrictions preventing the patient from engaging in structured social clubs, casual community gatherings, and visiting extended family and peer circles (Items 17, 21, 26).
• Interpersonal Dependency: Probes the psychological distress resulting from an involuntary reliance on domestic caregivers or healthcare providers for assistance with routine functional needs (Item 25).
• Intimate and Sexual Well-Being: Explicitly evaluates satisfaction with one’s sexual life (Item 23). In cardiac populations, sexual activity is frequently abandoned or severely compromised due to physiological fatigue, medication-induced erectile dysfunction, or crippling fear of coital myocardial ischemia, representing a central component of holistic quality of life.

5.4. Cross-Domain Item Overlap and Multi-Domain Construction

A distinctive psychometric feature of the KvL-H / MacNew is the intentional assignment of selected items to multiple subscales. For example, Item 6 (dyspnea) loads into both the Emotional and Physical domains, acknowledging that breathlessness in cardiac patients functions simultaneously as a physiological symptom and a profound trigger of panic and emotional dread. Similarly, Item 23 (sexual satisfaction) resides within both the Emotional and Social domains, reflecting its shared status as an intimate psychological experience and an interpersonal relational bond. This overlapping structure honors the complex systemic nature of chronic cardiovascular illness while maintaining high overall structural parsimony.

6. Theoretical Framework

The KvL-H / MacNew is grounded in modern biopsychosocial theory, synthesized with established paradigms of Health-Related Quality of Life and functional outcome modeling.

6.1. The Wilson and Cleary Model of Health-Related Quality of Life

The primary theoretical architecture supporting the instrument aligns closely with the conceptual model of patient outcomes formulated by Wilson and Cleary (1995). This framework conceptualizes health outcomes as a causal continuum bridging five distinct clinical and experiential tiers:

1. Biological and Physiological Variables: Coronary atherosclerosis, cellular myocardial necrosis, coronary perfusion deficits, and reduced left ventricular ejection fraction.
2. Symptom Status: Patient-perceived angina, shortness of breath, somatic exhaustion, and palpitations.
3. Functional Status: The capacity to walk, ascend stairs, engage in sexual intimacy, and execute occupational or domestic tasks.
4. General Health Perceptions: An integrated cognitive synthesis of one’s somatic state and systemic health outlook.
5. Overall Quality of Life: Subjective life satisfaction, emotional equilibrium, and social fulfillment.

Traditional cardiology measures operate predominantly at Tier 1 and occasionally Tier 2. The KvL-H explicitly captures the translation of Tier 1 and Tier 2 phenomena into Tier 3, Tier 4, and Tier 5 outcomes. It recognizes that biological lesions do not map linearly onto quality of life; rather, individual psychological resilience, coping styles, family support, and environmental factors moderate how physiological impairments manifest as subjective disability and emotional distress.

6.2. The World Health Organization ICF Paradigm

The scale embodies the World Health Organization’s International Classification of Functioning, Disability and Health (ICF) model. Within the ICF framework, human health is analyzed across three distinct levels: Body Functions and Structures (impairments), Activities (limitations), and Participation (restrictions). The KvL-H mirrors these strata directly: the physical symptom items probe cardiopulmonary body function impairments; items measuring stair climbing, walking, and household tasks capture activity limitations; and items addressing social activities, family life, and vocational roles measure societal participation restrictions.

6.3. Self-Efficacy and Cognitive Adaptation Theory

From a behavioral medicine perspective, the instrument draws substantially on Albert Bandura’s Social Cognitive Theory, particularly the construct of perceived self-efficacy. Recovery from an acute coronary event is dictated largely by a patient’s confidence in their physiological coping capacity. The KvL-H directly evaluates this mechanism through items assessing whether patients feel “confident and in control of life” and “confident that they can cope with their heart problem.” Without perceived self-efficacy, individuals frequently retreat into excessive sick-role behavior, regardless of objective physiological recovery.

7. Validity

The psychometric validity of the KvL-H / MacNew has been evaluated extensively across international cohorts, encompassing thousands of patients presenting with myocardial infarction, percutaneous coronary interventions, coronary artery bypass surgery, stable angina pectoris, and chronic heart failure.

7.1. Construct and Structural Validity

Construct validity has been established by testing explicit hypotheses regarding expected associations between KvL-H domain scores and related physiological, functional, and psychological constructs. Across validation cohorts, the KvL-H demonstrates strong structural validity, cleanly separating patients into distinct functional strata based on New York Heart Association (NYHA) functional class and Canadian Cardiovascular Society (CCS) angina grading. In empirical studies (Höfer et al., 2004; Dixon et al., 2002; van Elderen et al., 2000), patients presenting with NYHA Class I dyspnea achieved mean physical subscale scores significantly higher (typically ranging between 5.5 and 6.2) than those classified in NYHA Class III or IV (typically falling between 3.2 and 4.1, p < .001). Similar robust monotonic gradient decrements are observed across escalating CCS angina classes.

7.2. Convergent and Concurrent Validity

Convergent validity has been repeatedly corroborated via systematic correlations with established generic and condition-specific comparative instruments:

• Correlations with the SF-36: The KvL-H Physical domain correlates strongly with the SF-36 Physical Functioning (PF) and Role-Physical (RP) scales (r values spanning .62 to .78). The KvL-H Emotional domain correlates robustly with the SF-36 Mental Health (MH) and Role-Emotional (RE) subscales (r values ranging from .68 to .82), demonstrating convergent psychometric convergence.
• Correlations with Affective Inventories: When evaluated against the Hospital Anxiety and Depression Scale (HADS), the KvL-H Emotional domain demonstrates strong negative correlations with HADS-Depression (r = -.65 to -.76) and HADS-Anxiety (r = -.60 to -.73), confirming that lower emotional quality of life directly tracks escalating clinical depression and anxiety.
• Correlations with Functional Exercise Testing: Substantial moderate positive correlations have been consistently documented between the KvL-H Physical subscale and objective exercise capacity, including peak oxygen uptake (VO₂ peak, r = .40 to .55) and maximal workload achieved on bicycle ergometry or treadmill testing during baseline and post-rehabilitation evaluations.

7.3. Discriminant (Divergent) Validity

Discriminant validity is supported by the divergence between physiologically distinct domains. The KvL-H Emotional domain exhibits markedly weaker correlations with purely physical parameters, such as maximal ergometric wattages or left ventricular ejection fraction (r values routinely falling below .20). Furthermore, the instrument successfully discriminates between clinical subpopulations known to diverge in quality of life trajectory: female cardiac patients, older patients, and patients with high baseline comorbidity indices systematically exhibit distinct, lower domain profiles, mirroring established clinical epidemiological disparities.

7.4. Evaluative Validity and Responsiveness to Clinical Change

A crucial attribute of any rehabilitation PROM is its responsiveness—the capacity to register true clinical change over time. The KvL-H exhibits high evaluative responsiveness. In longitudinal cardiac rehabilitation evaluation studies, standardized response means (SRM) and effect sizes (Cohen’s d) following 6-to-12-week comprehensive rehabilitation programs routinely range from 0.60 to 1.10 across all three subscales, with the Physical and Emotional domains demonstrating the largest gains. Importantly, the minimal important difference (MID) for the instrument has been empirically established using both anchor-based and distribution-based methodologies at 0.50 points on the 1-to-7 score continuum. A change of 0.50 points represents a clinically meaningful improvement or deterioration noticeable to the patient and predictive of long-term prognostic trajectory.

8. Reliability

The reliability of the KvL-H and its parent MacNew/QLMI instruments has been verified across diverse linguistic populations, clinical settings, and disease severities, demonstrating strong internal consistency and temporal reproducibility.

8.1. Internal Consistency

Internal consistency reliability, measured via Cronbach’s alpha, consistently surpasses standard academic thresholds for both group-level research (alpha > .70) and individual-level clinical decision-making (alpha > .85):

• Total Global Scale: Cronbach’s alpha routinely ranges from .92 to .96, indicating an exceptionally cohesive overarching construct of health-related quality of life.
• Emotional Subscale: Cronbach’s alpha coefficients across international validation studies range from .88 to .93 (van Elderen et al., 2000 reported .91 in the Dutch KvL-H validation).
• Physical Subscale: Cronbach’s alpha coefficients range from .86 to .92 across post-MI and revascularization populations.
• Social Subscale: Cronbach’s alpha coefficients range from .84 to .89. Despite containing fewer items (7 items), the subscale retains high statistical cohesion without redundant item duplication.

8.2. Test-Retest Reliability

In stable cardiac outpatients assessed across time windows ranging from 3 days to 2 weeks (during which no therapeutic alterations or clinical deteriorations occurred), the instrument exhibited outstanding temporal stability:

• Intraclass correlation coefficients (ICC) for the global score routinely exceed .85, with published values spanning .82 to .94.
• Subscale-specific ICCs demonstrate consistent stability: Emotional (ICC = .80 to .91), Physical (ICC = .84 to .95), and Social (ICC = .76 to .88).
• Paired Student’s t-tests between baseline and short-term retest assessments across clinically stable cohorts indicate absence of systemic directional bias or memory recall confounding effects.

9. Factor Analysis

The factorial composition of the 27-item instrument has been interrogated across several decades utilizing both Exploratory Factor Analysis (EFA) and Confirmatory Factor Analysis (CFA) across diverse patient samples totaling over 10,000 international participants.

9.1. Exploratory Factor Analysis (EFA)

During the transition from the original 26-item QLMI to the 27-item MacNew/QLMI-2 structure, EFA utilizing principal component analysis with oblique (Promax or Oblimin) rotation systematically demonstrated the presence of three dominant, correlated factors corresponding to the Emotional, Physical, and Social domains:

• The three core factors routinely account for between 48% and 58% of the total explained variance across datasets.
• Factor 1 (Emotional) accounts for the largest share of variance (approximately 30% to 36%), reflecting the psychological burden accompanying cardiovascular diagnoses. Items 1, 2, 3, 4, 5, 7, 8, 10, 13, 15, and 18 load strongly onto this factor (loadings typically .55 to .84).
• Factor 2 (Physical) explains approximately 10% to 15% of variance, capturing items evaluating exertional physical limitation, specific ischemic chest pain, and dynamic mobility (Items 9, 12, 14, 16, 19, 20; loadings .50 to .82).
• Factor 3 (Social) explains an additional 5% to 8% of variance, grouping items addressing family role interference, social activity limits, and dependency (Items 17, 21, 22, 24, 25, 26; loadings .48 to .78).

9.2. Confirmatory Factor Analysis (CFA) and Model Fit

Subsequent psychometric investigations (e.g., Höfer et al., 2004; Dixon et al., 2002) subjected the hypothesized three-factor oblique model to rigorous Confirmatory Factor Analysis. Given the intentional theoretical design permitting cross-loading items (e.g., dyspnea on Physical and Emotional; sexual satisfaction on Emotional and Social), modern CFA specifications assess both pure three-factor orthogonal structures and correlated three-factor models incorporating designated dual-domain specifications:

• Comparative Fit Index (CFI): Values for the specified correlated three-factor model consistently exceed .90 to .93, indicating satisfactory to good fit across diverse international translation datasets.
• Tucker-Lewis Index (TLI): Estimates routinely achieve acceptable fit between .89 and .92.
• Root Mean Square Error of Approximation (RMSEA): Point estimates fall between .052 and .068 (with 90% confidence intervals remaining below .075), meeting established criteria for robust structural model fit.
• Standardized Root Mean Square Residual (SRMR): Values consistently remain beneath the .06 threshold.

Bifactor modeling has further supported the reporting of both a general HRQL score and domain-specific scores, confirming that while a strong general cardiac quality-of-life factor saturates the entire instrument, significant unique variance is captured within the distinct emotional, physical, and social subdomains.

10. Instrument / Measurement Tool

The operational administration characteristics, structural format, and quantitative scoring procedures of the KvL-H / MacNew Heart Disease HRQL Questionnaire are summarized below:

• Instrument Type: Disease-specific patient-reported outcome measure (PROM) / standardized psychological self-report questionnaire.
• Target Population: Adults (18 years and older) and elderly patients diagnosed with acute or chronic cardiovascular conditions, including acute myocardial infarction, stable or unstable angina pectoris, ischemic heart disease, heart failure, status-post coronary artery bypass graft (CABG) surgery, or percutaneous coronary intervention (PCI), participating in or eligible for cardiac rehabilitation.
• Administration Mode: Self-administered paper-and-pencil or digital/electronic format. (Historically originated as an interviewer-administered protocol [QLMI], but standardized as an autonomous self-report tool).
• Completion Time: Approximately 8 to 12 minutes to complete all 27 items.
• Recall Period: Standardized recall frame spanning the past 2 weeks (“during the past 2 weeks” / “in the past 2 weeks”).
• Item Count: Exactly 27 items.
• Response Format: Fully anchored 7-point Likert scale (1 = All of the time / Very dissatisfied / Severely limited to 7 = None of the time / Very satisfied / Not limited at all; specific response anchor wordings vary slightly depending on item stem, with 1 indicating poorest HRQL and 7 indicating highest HRQL).
• Subscale Composition:
  • Emotional Subscale (14 items): Items 1, 2, 3, 4, 5, 6, 7, 8, 10, 11, 13, 15, 18, and 23.
  • Physical Subscale (13 items): Items 6, 9, 12, 14, 16, 17, 19, 20, 21, 24, 25, 26, and 27.
  • Social Subscale (7 items): Items 17, 21, 22, 23, 24, 25, and 26.
• Scoring and Computational Rules:
  • Each item is scored directly from 1 to 7 according to the selected option, where 1 always denotes poorest HRQL and 7 denotes optimal HRQL. (Note: Positively worded items such as Items 3, 4, 5, 10, and 19 are anchored so that a score of 7 reflects “All of the time”, while negatively worded distress items are anchored so that a score of 7 reflects “None of the time” or “Not limited at all”, thereby obviating the need for post-hoc reverse coding transformations).
  • Emotional Subscale Score: Sum of answered Emotional items divided by the number of answered Emotional items (theoretical range: 1.0 to 7.0).
  • Physical Subscale Score: Sum of answered Physical items divided by the number of answered Physical items (theoretical range: 1.0 to 7.0).
  • Social Subscale Score: Sum of answered Social items divided by the number of answered Social items (theoretical range: 1.0 to 7.0).
  • Global / Overall HRQL Score: Sum of all answered items across the questionnaire divided by the total number of items answered (theoretical range: 1.0 to 7.0).
• Handling of Missing Data:
  • Item 23 (Sexual satisfaction) includes an explicit “Does not apply to me” or refusal contingency. If Item 23 is omitted or marked as not applicable, the subscale scores for Emotional and Social, as well as the Global score, are calculated by averaging the remaining validly answered items in those domains without imputation penalties.
  • A subscale score is considered invalid if more than 20% of the items contributing to that specific subscale are missing. The Global score is deemed valid if at least 22 of the 27 items are completed.

11. Permissions & Fee and Test Year

• Original Publication Year: 1991 (Original 26-item QLMI by Oldridge et al.); revised and standardized in 1996 as the 27-item QLMI-2 / MacNew; Dutch translation and clinical rehabilitation validation (KvL-H) published in 2000 by van Elderen, Maes, and colleagues.
• Copyright Holders: Original developmental copyright belongs to the original investigators (Neil Oldridge, Gordon Guyatt, et al.). The Dutch adapted instrument (KvL-H) is maintained and documented within Dutch cardiopulmonary rehabilitation frameworks (e.g., Nederlands Paramedisch Instituut / Leiden University).
• Licensing and Accessibility: The instrument is available for non-commercial academic research, non-funded academic dissertations, and routine public clinical audit without mandatory royalty fees, provided full formal citation and attribution are preserved. Commercial clinical trials, pharmaceutical sponsor evaluations, and proprietary digital health platforms may require formal licensing agreements and permissions. Researchers and clinicians should consult instrument user documentation or corresponding authors prior to implementation in funded registry frameworks.

12. References

• Dixon, T., Lim, L. L., & Oldridge, N. B. (2002). The MacNew illness-specific health-related quality of life instrument in patients with heart disease: Validity, reliability, and responsiveness. Journal of Clinical Epidemiology, 55(1), 27–34. https://doi.org/10.1016/S0895-4356(01)00411-9
• Höfer, S., Lim, L., Guyatt, G., & Oldridge, N. (2004). The MacNew Heart Disease health-related quality of life instrument: A review. Health and Quality of Life Outcomes, 2, Article 3. https://doi.org/10.1186/1477-7525-2-3
• Höfer, S., Saleem, A., Stone, J., Thomas, R., & Oldridge, N. (2012). The MacNew Heart Disease health-related quality of life questionnaire in patients with angina and patients with ischemic heart failure. Value in Health, 15(1), 143–150. https://doi.org/10.1016/j.jval.2011.08.1740
• Oldridge, N., Guyatt, G., Jones, N., Crowe, J., Singer, J., Feeny, D., Wheatley, B., Taylor, C., Duku, E., & Foster, G. (1991). Effects on quality of life with comprehensive rehabilitation after acute myocardial infarction. The American Journal of Cardiology, 67(13), 1084–1089. https://doi.org/10.1016/0002-9149(91)90870-Q
• Oldridge, N., Gottlieb, M., Guyatt, G., Feeny, D., Willmer, F., & Streiner, D. (1998). Predictors of health-related quality of life with cardiac rehabilitation after acute myocardial infarction. Journal of Cardiopulmonary Rehabilitation, 18(2), 95–103. https://doi.org/10.1097/00008483-199803000-00002
• van Elderen, T., Maes, S., & Dusseldorp, E. (1999). Coping with coronary heart disease: A longitudinal study. Journal of Psychosomatic Research, 47(2), 175–183. https://doi.org/10.1016/S0022-3999(99)00030-3
• van Elderen, T., Verhallen, M., & Maes, S. (2000). Kwaliteit van Leven bij Hartpatiënten (KvL-H): Handleiding en Psychometrische Eigenschappen van de Nederlandse MacNew. Afdeling Klinische en Gezondheidspsychologie, Universiteit Leiden.
• Wilson, I. B., & Cleary, P. D. (1995). Linking clinical variables with health-related quality of life: A conceptual model of patient outcomes. JAMA, 273(1), 59–65. https://doi.org/10.1001/jama.1995.03520250075037

13. Items of the Scale (Questionnaire)