The impact of the coronavirus disease 2019 (COVID-19) pandemic on the sustainability of quality of life (QOL) and the effects on social and human interactions have been reported worldwide .
So far, research has focused mainly on hospitalised COVID-19 patients in the acute setting, but the consequences after the acute stage are also relevant and deserve particular attention from healthcare professionals, not only to improve symptoms but also to restore QOL and work productivity.
Quality of life
The World Health Organization (WHO) defines QOL as "an individual's perception of their position in life in the context of the culture and value systems in which they live and in relation to their goals, expectations, standards and concerns" . In particular, health-related quality of life (HRQOL) is an evaluation of QOL and its relationship with health .
Different tools are available to measure HRQOL, as it has multidimensional components. It includes physical, psychological, functional, and social domains related to a person’s perception of QOL affected by health status. The most common questionnaires to assess HRQOL are the 36-item short-form (SF-36) survey  or the EuroQoL 5-domain 5-level (EQ-5D-5L) tool .
Impact on HRQOL can be different on an individual versus a collective level, as the first focuses more on personal well-being and individual rights, while the second seeks out help within a community, creating patient advocacy groups. During the COVID-19 pandemic, mainly through social media but not exclusively, groups were created by COVID-19 patients or healthy individuals to support each other all over the globe, such as the COVID Advocacy Exchange (https://theadvocacyexchange.com/) or the National Patient Advocate Foundation COVID Care Resource Centre (www.patientadvocate.org/covidcare) group. Cardiology societies all over the world, including the European Society of Cardiology , have also been called upon to offer guidance and to clarify the medical attitude towards patients with COVID-19 and cardiovascular diseases.
In this article we summarise the impact of COVID-19 on QOL and we underline the importance of identifying vulnerable persons for early interventions and for long-term follow-up.
Effect of COVID-19 on QOL
Symptoms related to COVID-19 can persist after recovery, with organ-specific sequelae requiring interdisciplinary comprehensive care. Post-COVID-19 syndrome has been clearly described , with the two most common persistent symptoms being fatigue and dyspnoea , which can occur irrespective of the severity of the initial illness .
From a psychological point of view, anxiety, depression and sleep disturbances have been reported in 30-40% of survivors of COVID-19. Of note, these values are similar to those of survivors of other pathogenic coronaviruses .
In a Chinese study, patients with COVID-19 were evaluated using the SF-36, showing a poor HRQOL at one-month follow-up, with psychological impairment described predominantly in females, suggesting that female sex could be a risk factor for mental health QOL in COVID-19 patients . Another Chinese study also using the SF-36 for QOL evaluation described how the HRQOL of patients hospitalised for COVID-19 showed impairments up to three months after discharge . In this study poor HRQOL seemed to be associated with age, sex and physical symptoms after discharge, and suggested that older persons, especially females and those with recurrent physical symptoms, were most at risk of a low HRQOL.
The term “long COVID” was defined by the National Institute for Health and Care Excellence guideline to characterise patients having signs and symptoms that continue or develop after acute COVID-19. It includes both ongoing symptomatic COVID-19 (from 4 to 12 weeks) or post-COVID-19 syndrome (≥12 weeks) . Patients who experience symptoms at 6 months after the acute infection, also seemed to have an impairment of their QOL, functional status and work productivity .
Neuropsychological evaluation in the post-acute illness setting should be offered to all COVID-19 survivors with a standard screening approach, in order to identify more vulnerable patients and begin early interventions and prompt treatment.
Impact on gender, age and race
Changes related to lockdown, and consequently to working routine and habits, had a huge impact on employment status and job performances. Moreover, with the economic crisis, many companies, restaurants and leisure centres have had to adapt and downsize employee numbers, up to the point of employees being partially paid or even forced to lose their jobs.
Gender inequality has been described particularly in relation to work changes. Actually, women were more at risk than men for unemployment, reductions in working hours and transitions to working from home, according to a study carried out in the USA, Germany and Singapore .
The impact on children versus adults also deserves attention. Effects of COVID-19 on HRQOL in adolescents and children have been reported in a systematic review  showing a clear reduction in HRQOL, irrespective of sex. In particular, a US study measured children’s well-being using the EQ-5D-5L questionnaire and showed a decreased HRQOL in younger adults aged between 18 and 24 years old, compared to the US population norms . These results suggest that the general lockdown and restrictions rules have definitely played a role in terms of the mental well-being of the younger generations.
Patients hospitalised for COVID-19 and aged 60 years and older seem to be the more susceptible to report a negative change in HRQOL at 6 months following discharge, assessed by the EQ-5D-5L questionnaire, according to a report on HRQOL including 216 hospitalised COVID-19 patients. Furthermore, one out of three experienced a persistently impaired mobility and ability to carry out activities of daily living .
Finally, different geographic areas with racial and ethnic differences played a role in the manifestation of COVID-19, showing a higher mortality in African Americans and drastic economic disruption in lower socio-economic classes . In certain areas, HRQOL was already low before the COVID-19 pandemic; therefore, the limited healthcare resources and poor medical access can explain the drastic outcomes in such countries, highlighting unequal impacts and exacerbation of existing inequalities.
Impact on physical activity
As cardiologists we have to be aware of the significant impact of COVID-19 on practising a physical activity. The drop in physical activity during this pandemic is intuitive for both healthy individuals and patients. If we take into account that access to sport was limited during the pandemic, we can imagine that QOL was impacted by the restricted access to training facilities, as well as the fear of going out and exercising. The closure of fitness centres and the cessation of club activities have greatly contributed to the observed decline in sports activities, and the behaviour of children and adolescents has unfortunately been comparable.
Regular practice of physical activity and sport remains the most powerful preventive measure of chronic diseases, but it is also a very good way to stimulate immunity.
In relation to cardiac rehabilitation, despite the fact that the majority of programmes had to be interrupted during the pandemic, the option of cardiac tele-rehabilitation was made available in some centres to patients with access to adequate technology, providing them with the option of continuing their physical activity programmes at home by distance learning . Even after the end of the COVID-19 pandemic, the option of tele-rehabilitation is expected to continue to be developed and could soon be integrated into standard care.
The psychological well-being of people has been interrupted by disturbing their social, economic and environmental peace. In addition, chronic stressors imposed on people by the different way restrictions, either directly or indirectly, have to be taken in consideration. In order to face the current burden of post-COVID-19 syndrome and the impairment on HRQOL, we have to identify the most vulnerable persons and be prepared for an optimal intervention.
Interventions at different levels should be offered: frequent follow-up visits, the possibility of participating in rehabilitation programmes, and the opportunity to practise yoga, mindfulness or meditation in order to decrease the level of stress. Slow, progressive and supervised physical and sports activity could promote recovery in post-COVID-19 syndrome and certainly improve QOL.
Finally, the huge improvement in telemedicine and mobile health (m-health) technology during the COVID-19 pandemic has been very helpful, with the possibility of on-line medical consultations, thanks also to the development of different medical applications for smartphones.
Because of the impact on people’s mindsets, there is a clear actual need to cooperate and to improve QOL, maintaining a positive attitude, promoting a healthy lifestyle and identifying the most vulnerable categories in order to intervene as early as possible.
- The lesson learnt so far from this pandemic should be “semper paratus” (“always prepared”): in patients with COVID-19, not only their physical well-being, but also their QOL has to be taken into consideration.
- After the acute phase of COVID-19, not only younger adults but also older persons with recurrent physical symptoms seem to be at greater risk of a low HRQOL.
- Thanks to mobile health technology, such as applications for smartphones, patients surviving COVID-19 and requiring rehabilitation programmes should be aware of different online programs to progress in their clinical status, and also to improve their HRQOL.
- During this pandemic cardiologist should endeavour to encourage individuals to practise regular physical activity and lead a healthy lifestyle, not only to safeguard the cardiovascular system, but also to ensure and promote the general well-being of each individual.