Seattle Angina Questionnaire (SAQ)

There are no widely accepted measures assessing the functional status of those with coronary disease. (Ref: 1) Spertus et al. mentions that the optimal measure should quantify the routine exertion level of the patient, the frequency of angina, the patient’s satisfaction with the treatment regime, and the quality of life limitations caused by coronary disease (patient perspective). (Ref: 1) The Seattle Angina Questionnaire (SAQ) addresses these concerns, specifically focusing on quantifying angina-related physical and emotional effects. (Ref: 1)

The SAQ is a self-administered questionnaire, consisting of 19 items and 5 scales. (Ref: 1) The constructs, or scales, addressed in the measure are: disease perception, treatment satisfaction, physical limitation, angina stability and anginal frequency. The physical limitation scale was derived from various scales and the angina frequency scale was adopted from the Angina Questionnaire. (Ref: 1)

The physical limitation scale presents items beginning with simple activities and progresses to more extraneous tasks. Degree of limitation is due to “chest pain, chest tightness, or angina” The physical limitation scale has responses ranging from “severely limited” to “not limited,” plus a “did not do for other reasons” response. The angina stability scale is a single item measuring the occurrence(s) of angina at the patient’s most extraneous activity level obtained and compared to occurrences four weeks prior. The angina stability scale utilizes a 5-point system ranging from “much more often” to “much less often”. The angina frequency scale consists of two items and utilizes a 6-point scale ranging from “four or more occurrences” to “no occurrences.” Treatment satisfaction is measured by four items on a 5-point scale with responses ranging from dissatisfaction with treatment to a patient-perceived satisfaction with treatment. Lastly, disease perception is measured by three items on a 5-point scale with responses ranging from a patient-perceived poor quality of life to a patient-perceived better quality of life.

$125; Available at the website under

The questionnaire takes less than 5 minutes to complete. (Ref: 1,3)

1995 (original articles were published in 1994)

The Flesch-Kincaid reading grade level is 8.1, indicating that subjects completing the 8th grade can understand the questionnaire. There is an average of 20 words per item and no negatively worded items.

Items in the SAQ have ordinal (Likert-type) responses, ranging from one extreme to the other. The scales range from 5-point response systems to 6-point response systems.

Self-administered. (Ref: 1)

Responses in the SAQ are given ordinal values. Items that correspond to the lowest level of functioning are assigned a value of one, while items that correspond to higher functioning levels are assigned a higher ordinal value. These scores are converted to a 100-point score by subtracting the lowest possible scale score, dividing it by the response range and multiplying it by 100. Generally, a higher score indicates the patient’s ability to exert higher functional levels. Each scale measures and consists of its own score descriptions. (Ref: 1) There is no total instrument score. One study defined the interpretation of the angina frequency and physical limitation scores as severe (0-24), moderate (25-49), mild (50-74) and minimal (75-100). Angina frequency ranges from severe (several times per day) to minimal angina (less than once a week). Angina stability scores range from much better (100-76) to poor (24-0). (Ref: 6) Lastly, for the treatment satisfaction and disease perception scales, higher scores indicate high treatment satisfaction and disease perception.

This questionnaire is available in multiple languages including English, French, Danish, Dutch, French, Italian, Norweigian, Swedish and Spanish. Refer to the SAQ ordering website for further details (http://www.outcomes-trust.org).

John A Spertus, MD, MPH

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The SAQ is available at http://www.outcomes-trust.org.

jspertus@cctr.umkc.edu

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Researchers conducted an exploratory factor analysis and found that five factors contained eigenvalues over one, and accounted for 70.2% of the variance. Single item factor loading had to contain a value of 0.50 or more to be included in a specific factor. (Ref: 7) Factors and variances are presented below:

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The SAQ demonstrated stable results in the test-retest calculations over a two-week period, with the exception of the “angina stability scale” score (r=0.33). (Ref: 3) Similarly, Spertus et al. noted stability of mean score of all SAQ scales over a three-month period. P values ranged from 0.1 (angina stability) to 0.77 (treatment satisfaction). (Ref: 1)

The SAQ is a self-administered questionnaire; therefore, inter rater reliability does not apply.

Cronbach’s alpha was calculated for the SAQ subscales and results are as follows: physical limitation (0.89), angina frequency (0.87) treatment satisfaction (0.77) and disease perception (0.66). The angina stability scale did not have a score, since it contains only one question. (Ref: 3)

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Researchers compared the SAQ to the SF-36 and the Quality of Life Index-Cardiac Version III (QLI) and found a high level of agreement on similar dimensions. For example, the SAQ physical limitation scale and the physical functioning scale of the SF-36 correlated significantly (r=0.63, p=0.000). The SF-36 physical component scale (r=0.59, p=0.000) and the QLI health and functioning scale correlated with the SAQ physical limitation scale (r=0.46, p=0.000). (Ref: 3)

The Canadian Cardiovascular Society Classification (CCSC) was used as a gold standard in evaluating the SAQ, SF-36 and QLI. (Ref: 3) It was noted that as angina impairment increased, per CCSC, the SAQ scores decreased (with the exception of the treatment satisfaction scale scores). P values are as follows: physical limitation (0.002), angina frequency (0.0001), angina stability (0.0035), treatment satisfaction (0.97) and disease perception (0.005). (Ref: 3) Lastly, another study assessed the relationship between total exercise duration and scores of the SAQ, the Specific Activity Scale and the Duke Activity Status Index. (Ref: 1) Results indicated that the SAQ and DASI scores were significantly related to total exercise duration (r=0.42, p<0.001 & r=0.40, p<0.001 respectively) and with each other (r=0.43, p<0.001). (Ref: 1)

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With the implementation of angioplasty, all scores within a 3-month period dramatically improved, with the exception of the treatment satisfaction scores. (Ref: 1-2) Similarly, coronary artery bypass surgery (CABG) yielded similar results in, a three-month time span, with improved scores in all SAQ subscales (p < .0001), except for the treatment satisfaction scale. (Ref: 4) Anginal medication treatments caused a statistically significant change in SAQ scores over the three-month period, P=0.000, except for the physical limitation scale, (p=0.40 (Ref: 3), p=0.82 (Ref: 5)

Yes. (Ref: 1-3,5-6)

Yes. (Ref: 4,7)