Quality of Life Research

, Volume 26, Issue 8, pp 2219–2228 | Cite as

Quality of life independently predicts long-term mortality but not vascular events: the Northern Manhattan Study

  • John W. LiangEmail author
  • Ying Kuen Cheung
  • Joshua Z. Willey
  • Yeseon P. Moon
  • Ralph L. Sacco
  • Mitchell S. V. Elkind
  • Mandip S. Dhamoon



Cardiovascular disease is a major contributor to morbidity and mortality, and prevention relies on accurate identification of those at risk. Studies of the association between quality of life (QOL) and mortality and vascular events incompletely accounted for depression, cognitive status, social support, and functional status, all of which have an impact on vascular outcomes. We hypothesized that baseline QOL is independently associated with long-term mortality in a large, multi-ethnic urban cohort.


In the prospective, population-based Northern Manhattan Study, Spitzer QOL index (SQI, range 0–10, with ten signifying the highest QOL) was assessed at baseline. Participants were followed over a median 11 years for stroke, myocardial infarction (MI), and vascular and non-vascular death. Multivariable Cox proportional hazards regression estimated hazard ratio and 95% confidence interval (HR, 95% CI) for each outcome, with SQI as the main predictor, dichotomized at 10, adjusting for baseline demographics, vascular risk factors, history of cancer, social support, cognitive status, depression, and functional status.


Among 3298 participants, mean age was 69.7 + 10.3 years; 1795 (54.5%) had SQI of 10. In fully adjusted models, SQI of 10 (compared to SQI <10) was associated with reduced risk of all-cause mortality (HR 0.80, 95% CI 0.72–0.90), vascular death (0.81, 0.69–0.97), non-vascular death (0.78, 0.67–0.91), and stroke or MI or death (0.82, 0.74–0.91). In fully adjusted competing risk models, there was no association with stroke (0.93, 0.74–1.17), MI (0.98, 0.75–1.28), and stroke or MI (1.03, 0.86–1.24). Results were consistent when SQI was analyzed continuously.


In this large population-based cohort, highest QOL was inversely associated with long-term mortality, vascular and non-vascular, independently of baseline primary vascular risk factors, social support, cognition, depression, and functional status. QOL was not associated with non-fatal vascular events.


Quality of life Patient-centered outcomes Prospective Cohort Vascular outcomes 



This work was supported by grants from the National Institute of Neurological Disorders and Stroke (R01 NS48134, MSVE; R37 29993, RLS/MSVE).

Compliance with ethical standards

Conflict of interest

None of the authors has a financial relationship or conflict of interest relevant to the topic of the manuscript.

Supplementary material

11136_2017_1567_MOESM1_ESM.pdf (9 kb)
Supplementary material 1 (PDF 9 KB)


  1. 1.
    Mozaffarian, D., Benjamin, E. J., Go, A. S., et al. (2016). Executive summary: Heart disease and stroke statistics-2016 update: A report from the american heart association. Circulation, 133, 447–454.CrossRefPubMedGoogle Scholar
  2. 2.
    Lozano, R., Naghavi, M., Foreman, K., et al. (2012). Global and regional mortality from 235 causes of death for 20 age groups in 1990 and 2010: A systematic analysis for the Global Burden of Disease Study 2010. Lancet, 380, 2095–2128.CrossRefPubMedGoogle Scholar
  3. 3.
    McEwen, L. N., Kim, C., Haan, M. N., et al. (2009). Are health-related quality-of-life and self-rated health associated with mortality? Insights from Translating Research Into Action for Diabetes (TRIAD). Primary Care Diabetes, 3, 37–42.CrossRefPubMedPubMedCentralGoogle Scholar
  4. 4.
    Rodriguez-Artalejo, F., Guallar-Castillon, P., Pascual, C. R., et al. (2005). Health-related quality of life as a predictor of hospital readmission and death among patients with heart failure. Archives of Internal Medicine, 165, 1274–1279.CrossRefPubMedGoogle Scholar
  5. 5.
    Hansen, T. B., Thygesen, L. C., Zwisler, A. D., et al. (2015). Self-reported health-related quality of life predicts 5-year mortality and hospital readmissions in patients with ischaemic heart disease. European Journal of Preventive Cardiology, 22, 882–889.CrossRefPubMedGoogle Scholar
  6. 6.
    Hofer, S., Benzer, W., & Oldridge, N. (2014). Change in health-related quality of life in patients with coronary artery disease predicts 4-year mortality. International Journal of Cardiology, 174, 7–12.CrossRefPubMedGoogle Scholar
  7. 7.
    Gotay, C. C., Kawamoto, C. T., Bottomley, A., & Efficace, F. (2008). The prognostic significance of patient-reported outcomes in cancer clinical trials. Journal of Clinical Oncology : Official Journal of the American Society of Clinical Oncology, 26, 1355–1363.CrossRefGoogle Scholar
  8. 8.
    Pearson S, Stewart S, Rubenach S. (1999). Is health-related quality of life among older, chronically ill patients associated with unplanned readmission to hospital? Australian and New Zealand Journal of Medicine, 29, 701–6.CrossRefPubMedGoogle Scholar
  9. 9.
    Myint, P. K., Luben, R. N., Surtees, P. G., Wainwright, N. W., Wareham, N. J., & Khaw, K. T. (2010). Physical functional health predicts the incidence of coronary heart disease in the European Prospective Investigation into Cancer-Norfolk prospective population-based study. International Journal of Epidemiology, 39, 996–1003.CrossRefPubMedGoogle Scholar
  10. 10.
    Myint, P. K., Surtees, P. G., Wainwright, N. W., et al. (2007). Physical health-related quality of life predicts stroke in the EPIC-Norfolk. Neurology, 69, 2243–2248.CrossRefPubMedGoogle Scholar
  11. 11.
    Xie, G., Zou, H., Myint, P. K., et al. (2016). Baseline overall health-related quality of life predicts the 10-year incidence of cardiovascular events in a Chinese population. Quality of Life Research: An International Journal of Quality of Life Aspects of Treatment, Care and Rehabilitation, 25, 363–371.CrossRefGoogle Scholar
  12. 12.
    Munoz, M. A., Subirana, I., Elosua, R., et al. (2011). Utility of a short quality of life questionnaire to predict cardiovascular events. International Journal of Cardiology, 151, 392–394.CrossRefPubMedGoogle Scholar
  13. 13.
    Xie, G., Laskowitz, D. T., Turner, E. L., et al. (2014). Baseline health-related quality of life and 10-year all-cause mortality among 1739 Chinese adults. PloS ONE, 9, e101527.CrossRefPubMedPubMedCentralGoogle Scholar
  14. 14.
    Haring, R., Feng, Y. S., Moock, J., et al. (2011). Self-perceived quality of life predicts mortality risk better than a multi-biomarker panel, but the combination of both does best. BMC Medical Research Methodology, 11, 103.CrossRefPubMedPubMedCentralGoogle Scholar
  15. 15.
    Ul-Haq, Z., Mackay, D. F., & Pell, J. P. (2014). Association between physical and mental health-related quality of life and adverse outcomes; a retrospective cohort study of 5,272 Scottish adults. BMC Public Health, 14, 1197.CrossRefPubMedPubMedCentralGoogle Scholar
  16. 16.
    Kaplan, M. S., Berthelot, J. M., Feeny, D., McFarland, B. H., Khan, S., & Orpana, H. (2007). The predictive validity of health-related quality of life measures: mortality in a longitudinal population-based study. Quality of Life Research : An International Journal of Quality of Life Aspects of Treatment, Care and Rehabilitation, 16, 1539–1546.CrossRefGoogle Scholar
  17. 17.
    Giltay, E. J., Vollaard, A. M., & Kromhout, D. (2012). Self-rated health and physician-rated health as independent predictors of mortality in elderly men. Age and Ageing, 41, 165–171.CrossRefPubMedGoogle Scholar
  18. 18.
    Huohvanainen, E., Strandberg, A. Y., Stenholm, S., Pitkala, K. H., Tilvis, R. S., & Strandberg, T. E. (2016). Association of self-rated health in midlife with mortality and old age frailty: A 26-year follow-up of initially healthy men. The Journals of Gerontology Series A, Biological Sciences and Medical Sciences, 71, 923–928.CrossRefPubMedGoogle Scholar
  19. 19.
    Barger, S. D., Cribbet, M. R., & Muldoon, M. F. (2016). Participant-reported health status predicts cardiovascular and all-cause mortality independent of established and nontraditional biomarkers: Evidence from a representative US sample. Journal of the American Heart Association, 5(9), e003741.CrossRefPubMedPubMedCentralGoogle Scholar
  20. 20.
    Jerant, A., Tancredi, D. J., & Franks, P. (2011). Mortality prediction by quality-adjusted life year compatible health measures: findings in a nationally representative US sample. Medical Care, 49, 443–450.CrossRefPubMedGoogle Scholar
  21. 21.
    Jia, H., Zack, M. M., Thompson, W. W., Crosby, A. E., & Gottesman, I. I. (2015). Impact of depression on quality-adjusted life expectancy (QALE) directly as well as indirectly through suicide. Social Psychiatry and Psychiatric Epidemiology, 50, 939–949.CrossRefPubMedPubMedCentralGoogle Scholar
  22. 22.
    Jia, H., & Lubetkin, E. I. (2017). Incremental decreases in quality-adjusted life years (QALY) associated with higher levels of depressive symptoms for U.S. Adults aged 65 years and older. Health and Quality of Life Outcomes, 15, 9.CrossRefPubMedPubMedCentralGoogle Scholar
  23. 23.
    Stafford, L., Berk, M., Reddy, P., & Jackson, H. J. (2007). Comorbid depression and health-related quality of life in patients with coronary artery disease. Journal of Psychosomatic Research, 62, 401–410.CrossRefPubMedGoogle Scholar
  24. 24.
    Rutledge, T., Linke, S. E., Johnson, B. D., et al. (2010). Self-rated versus objective health indicators as predictors of major cardiovascular events: the NHLBI-sponsored Women’s Ischemia Syndrome Evaluation. Psychosomatic Medicine, 72, 549–555.CrossRefPubMedPubMedCentralGoogle Scholar
  25. 25.
    Onawola, R. S., & LaVeist, T. A. (1998). Subjective health status as a determinant of mortality among African-American elders. Journal of the National Medical Association, 90, 754–758.PubMedPubMedCentralGoogle Scholar
  26. 26.
    Elkind, M. S., Sciacca, R., Boden-Albala, B., Rundek, T., Paik, M. C., & Sacco, R. L. (2006). Moderate alcohol consumption reduces risk of ischemic stroke: The Northern Manhattan Study. Stroke; A Journal of Cerebral Circulation, 37, 13–19.CrossRefGoogle Scholar
  27. 27.
    Willey, J. Z., Paik, M. C., Sacco, R., Elkind, M. S., & Boden-Albala, B. (2010). Social determinants of physical inactivity in the Northern Manhattan Study (NOMAS). Journal of Community Health, 35(6), 602–608CrossRefGoogle Scholar
  28. 28.
    Sacco, R. L., Anand, K., Lee, H. S., et al. (2004). Homocysteine and the risk of ischemic stroke in a triethnic cohort: the NOrthern MAnhattan Study. Stroke; A Journal of Cerebral Circulation, 35, 2263–2269.CrossRefGoogle Scholar
  29. 29.
    Gentry, E. M., Kalsbeek, W. D., Hogelin, G. C., et al. (1985). The behavioral risk factor surveys: II. Design, methods, and estimates from combined state data. American Journal of Preventive Medicine, 1, 9–14.PubMedGoogle Scholar
  30. 30.
    Mahoney, F. I., & Barthel, D. W. (1965). Functional evaluation: The Barthel Index. Maryland State Medical Journal, 14, 61–65.PubMedGoogle Scholar
  31. 31.
    Granger, C. V., Dewis, L. S., Peters, N. C., Sherwood, C. C., & Barrett, J. E. (1979). Stroke rehabilitation: Analysis of repeated Barthel index measures. Archives of Physical Medicine and Rehabilitation, 60, 14–17.PubMedGoogle Scholar
  32. 32.
    Spitzer, W. O., Dobson, A. J., Hall, J., et al. (1981). Measuring the quality of life of cancer patients: A concise QL-index for use by physicians. Journal of Chronic Diseases, 34, 585–597.CrossRefPubMedGoogle Scholar
  33. 33.
    Addington-Hall, J. M., MacDonald, L. D., & Anderson, H. R. (1990). Can the Spitzer Quality of Life Index help to reduce prognostic uncertainty in terminal care? British Journal of Cancer, 62, 695–699.CrossRefPubMedPubMedCentralGoogle Scholar
  34. 34.
    Dapueto, J. J., Francolino, C., Servente, L., et al. (2003). Evaluation of the functional assessment of cancer therapy-general (FACT-G) Spanish Version 4 in South America: Classic psychometric and item response theory analyses. Health and Quality of Life Outcomes, 1, 32.CrossRefPubMedPubMedCentralGoogle Scholar
  35. 35.
    Echt, D. S., Liebson, P. R., Mitchell, L. B., et al. (1991). Mortality and morbidity in patients receiving encainide, flecainide, or placebo. The Cardiac Arrhythmia Suppression Trial. The New England Journal of Medicine, 324, 781–788.CrossRefPubMedGoogle Scholar
  36. 36.
    Schaefer, E. J., Lamon-Fava, S., Jenner, J. L., et al. (1994). Lipoprotein(a) levels and risk of coronary heart disease in men. The lipid Research Clinics Coronary Primary Prevention Trial. Jama, 271, 999–1003.CrossRefPubMedGoogle Scholar
  37. 37.
    Sacco, R. L., Gan, R., Boden-Albala, B., et al. (1998). Leisure-time physical activity and ischemic stroke risk: The Northern Manhattan Stroke Study. Stroke; A Journal of Cerebral Circulation, 29, 380–387.CrossRefGoogle Scholar
  38. 38.
    Willey, J. Z., Paik, M. C., Sacco, R., Elkind, M. S., & Boden-Albala, B. (2010). Social determinants of physical inactivity in the Northern Manhattan Study (NOMAS). Journal of Community Health, 35, 602–608.CrossRefPubMedPubMedCentralGoogle Scholar
  39. 39.
    Dorr, D. A., Jones, S. S., Burns, L., et al. (2006). Use of health-related, quality-of-life metrics to predict mortality and hospitalizations in community-dwelling seniors. Journal of the American Geriatrics Society, 54, 667–673.CrossRefPubMedGoogle Scholar
  40. 40.
    Mikkelsen, S. S., Mortensen, E. L., & Flensborg-Madsen, T. (2014). A prospective cohort study of quality of life and ischemic heart disease. Scandinavian Journal of Public Health, 42, 60–66.CrossRefPubMedGoogle Scholar
  41. 41.
    Dadjou, Y., Kermani-Alghoraishi, M., Sadeghi, M., et al. (2016). The impact of health-related quality of life on the incidence of ischaemic heart disease and stroke; a cohort study in an Iranian population. Acta Cardiologica, 71, 221–226.CrossRefPubMedGoogle Scholar
  42. 42.
    Olson, K. L., Stiefel, M., Ross, C., et al. (2016). Self-rated health among patients with coronary artery disease enrolled in a cardiovascular risk reduction service. Population Health Management, 19, 24–30.CrossRefPubMedGoogle Scholar
  43. 43.
    Bosworth, H. B., Siegler, I. C., Brummett, B. H., et al. (1999). The association between self-rated health and mortality in a well-characterized sample of coronary artery disease patients. Medical Care, 37, 1226–1236.CrossRefPubMedGoogle Scholar
  44. 44.
    Fried LP, Tangen CM, Walston J, et al. (2001). Frailty in older adults: Evidence for a phenotype. The Journals of Gerontology Series A, Biological Sciences and Medical Sciences, 56, M146-M156.CrossRefGoogle Scholar
  45. 45.
    Klein, B. E., Klein, R., Knudtson, M. D., & Lee, K. E. (2005). Frailty, morbidity and survival. Archives of Gerontology and Geriatrics, 41, 141–149.CrossRefPubMedGoogle Scholar
  46. 46.
    Varadhan, R., Seplaki, C. L., Xue, Q. L., Bandeen-Roche, K., & Fried, L. P. (2008). Stimulus-response paradigm for characterizing the loss of resilience in homeostatic regulation associated with frailty. Mechanisms of Ageing and Development, 129, 666–670.CrossRefPubMedPubMedCentralGoogle Scholar
  47. 47.
    Kroenke, C. H., Kubzansky, L. D., Adler, N., & Kawachi, I. (2008). Prospective change in health-related quality of life and subsequent mortality among middle-aged and older women. American Journal of Public Health, 98, 2085–2091.CrossRefPubMedPubMedCentralGoogle Scholar
  48. 48.
    Hopman, W. M., Berger, C., Joseph, L., et al. (2006). The natural progression of health-related quality of life: results of a five-year prospective study of SF-36 scores in a normative population. Quality of Life Research: An International Journal of Quality of Life Aspects of Treatment, Care and Rehabilitation, 15, 527–536.CrossRefGoogle Scholar

Copyright information

© Springer International Publishing Switzerland 2017

Authors and Affiliations

  • John W. Liang
    • 1
    • 2
    Email author
  • Ying Kuen Cheung
    • 3
  • Joshua Z. Willey
    • 4
  • Yeseon P. Moon
    • 4
  • Ralph L. Sacco
    • 5
    • 6
  • Mitchell S. V. Elkind
    • 4
    • 7
  • Mandip S. Dhamoon
    • 1
  1. 1.Department of NeurologyIcahn School of MedicineNew YorkUSA
  2. 2.Divisions of Cerebrovascular Disease, Critical Care and NeurotraumaThomas Jefferson UniversityPhiladelphiaUSA
  3. 3.Department of Biostatistics, Mailman School of Public HealthColumbia UniversityNew YorkUSA
  4. 4.Department of Neurology, College of Physicians and SurgeonsColumbia UniversityNew YorkUSA
  5. 5.Department of Neurology, Evelyn F. McKnight Brain Institute, Miller School of MedicineUniversity of MiamiMiamiUSA
  6. 6.Departments of Public Health Sciences and Human Genetics, Miller School of MedicineUniversity of MiamiMiamiUSA
  7. 7.Department of Epidemiology, Mailman School of Public HealthColumbia UniversityNew YorkUSA

Personalised recommendations