Patients Expectations for Future Examination and Treatment

Patients will be asked to participate in the study, in the context of medical consultation before coronary angiography by a physician and / or a study nurse. This occurs during an outpatient visit at the cardiac clinic at the respective centre.

Included are all patients planned for elective coronary angiography before possible revascularization during a eight month period at SKAS, NÄL, SÄS and Sahlgrenska University Hospital, this regardless of diagnosis.

Patient informed consent (attached appendix) is given to the patient before coronary angiography at the out patient visit at the cardiac clinic at the respective centre, both verbally and in writing by physician and/or nurse at the time of consultation about participation in the study. At this time the approval is signed by concerned parties. This is desired to be done only by a nurse as there is no intervention in the study. The patient has to fill out three questionnaires at two occasions (but the 10 first patients included in the reliability tests have to fill out the expectancy form a total of three times including questions about the reliability of the questionnaire). The patient also has to leave two additional blood samples.

Patients answer a questionnaire developed to measure the expectations of treatment and questionnaires measuring quality of life and presence and degree of angina pectoris, (SF-36 and SAQ Seattle Angina Questionnaire). The form of expectations is validated against the "quality of life" forms. Blood samples are taken at inclusion and again after six months and are analyzed for NTproBNP, a biochemical measure of how much strain the coronary artery disease puts on the heart muscle. We want to examine whether levels of NTproBNP before and six months after coronary angiography correlates with quality of life and expectations before the inquiry and to what extent the expectations are met. To ensure equal treatment, it is important to build a patient perspective and set offered treatment and the availability of this, in relation to the individual patient's expectations.

The following three instruments will be used to measure symptoms, functional limitation, and expectations:

• SAQ (Seattle Angina Questionnaire) is primarily formulated to measure functional status of patients with coronary artery disease. SAQ consists of 19 five-scale questions, physical limitation (nine questions), angina grade (one question), frequency of angina (two questions), satisfaction of treatment (two questions) and perception of disease (five questions), and therefore measures dimensions of physical limitations, angina degree, satisfaction of treatment and Perception of illness. The form takes about five minutes to fill in. It is not a general measurement of quality of life (7).
• SF-36 partially consists of scales measuring physical function (10 questions), role functioning-physical causes (four questions), role function-emotional reasons (three questions), social functioning (two questions) and pain (two questions), It also consists of scales for welfare, measuring mental health (five questions), vitality (four questions), general health (five questions) and change in health (one question). This instrument takes five-10 minutes to complete (8.9).
• The Expectation Form is an own developed instrument consisting of a questionnaire with 11 questions about expectations for future care and treatment, and a follow-up questionnaire six months later, to examine whether the expectations of the patient had been met. The form takes about five minutes to fill in.

The form will be evaluated and validated as follows (10):

• Reliability-test will be done by four experienced professionals, knowledgeable in the topic reviewing the questionnaire.
• The first 10 enrolled patients complete the questionnaire. This is made at an additional occasion at the time of angiography. We do a 'test re-test, with about a week apart from test to re-test. At this additional occasion patients will also answer questions about how the questionnaire was to fill in i.e. a check of the user friendliness and on how the understanding of the form was.
• Validation of the form is done with SF-36, SAQ, and NTproBNP as the criteria. All data are clinically relevant and should be recorded in the patient's medical record according to standard procedures. Case Record Form (CRF) will be coded and anonymous, and a code list will be stored at a research nurse at each, included hospital. Decoded CRF are sent to and stored at Sahlgrenska University Hospital, at the department of Cardiology. Processing and statistical data is coded and anonymous. The people managing the data are those involved in the study as well as the cardiologist research unit's coordination staff and monitoring staff.

Ethical issues must always be considered in studies where people with chronic and serious illnesses are included. Requirements for information about the study and the opportunity to connect with those responsible, respect for integrity and that none shall be harmed are fundamental ethical principles that must be followed. Anonymity and confidentiality will be guaranteed. It is also important to clarify the possibility of ending participation in the study with no consequences for further care and treatment.

Out of a privacy standpoint, there is a risk that the patient may feel exposed after filling in the questionnaire relating to life situation, personal health and the relationship with health care. We will be informing patients carefully about how we handle data and that no data may be linked to individual patients when they are compiled and presented. data is entered and managed via the Cardiology Research Unit, Sahlgrenska University Hospital. These data are available to researchers participating in the study. The lead applicant is responsible for data processing (with Statisticians) and is primarily responsible for the report.

Statistic:Data processing and statistical analysis will be done in consultation with statisticians. For about eight months, we expect, based on past experience, to be able to include 800 consecutive patients undergoing elective coronary angiography at SKAS, NÄL, SÄS and Sahlgrenska University hospital. Of these, about half is estimated to have coronary artery disease and the rest of the surveys done as part of the investigation of other cardiovascular disease as valvular disease or heart failure. The gender distribution is estimated to be about 70% men and 30% women. Dichotomous variables (baseline characteristics) are given in the frequency and compared between sexes with the chi 2 or Fisher's exact test when appropriate. Continuous variables are presented as mean values with standard deviations and compared by Student t-test. Comparisons between different age groups are made by ANOVA.

Answer from the quality of life and degree of angina pectoris instruments, converted to scores according to established schedules. Comparison of scores at baseline and six months after the angiography will be done with paired Student t-test and between groups with two-way ANOVA, or with non-parametric tests depending on the distribution of the data. The form of expectations will be analyzed to answer each question using statistics as above. The study is explorative why customary power calculation is not done. As indicated above, expected patient material will be heterogeneous with respect to clinical condition, indication for angiography, sex and age. It is therefore important to collect as many materials as possible in order to compare different groups. Based on the SF 36 it can be stated that about 50 patients in each of two groups is needed if one is to detect differences in the range of five points (total points of this instrument is often 45-50 depending on the patient group it is about) with five-point standard deviation, 0.05 and power of 80%.