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Physical

component

improved Quality score

HRQOL

instruments Conclusion

nil **

The presence of

more than four

viable segments

(24% of the left

ventricle) on

with Heart Failure

(MLHF) scale

MPI in patients

with ischaemic

heart failure

before CABG

surgery is

signicantly

correlated with

the improvement

in LVEF, heart

failure

symptoms and

quality of life

post- operatively

Physical mobility

signicantly

improved

post-operatively

(70% of patients

The predictive

factors for

quality of life

worsening

6months after

Health Prole

Questionnaire

improved)

CABG are

female gender,

diabetes

mellitus, low

Y. S. Abdullahi et al.

ejection fraction,

and the presence

of postoperative

complications

No. of

patients

Table 3.2 (continued)

Follow-up duration

(mean)

65 56±15 14±4months Minnesota Living

baseline Age of patients

Prospective

cohort study

Patients with

ischaemic

cardiomyopathy

Peovska,

Author, year,

2008 [33]

Ref Intervention Study type

undergoing CABG

more than four

viable segments

N=39

Patients with

ischaemic

cardiomyopathy

undergoing CABG

less than four

viable segments

N=26

6months The Nottingham

58.2± 8

Females,

61.5±5.6

208 Male

Prospective

cohort study

Patients undergoing

elective CABG

n=208

Peric, 2008

[34]

3 What Factors Predict an Improved Quality of Life Outcome Following Coronary Artery Bypass Graft…

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(continued)

Physical

PCS improved

component

improved Quality score

HRQOL

instruments Conclusion

Follow-up duration

(mean)

from baseline (40)

to 42.2 post-

operatively which

was statistically

signicant

improvements in

HRQL

measures,

including two of

three subjective

neurocognitive

Nil **

depression

measures

symptoms

before and after

surgery showed

an association

with lower and

worse HRQOL

for vitality and

social role

functioning and

physical and

general health

Nil **********

The HRQoL of

SSIC patients is

similar to

patients

receiving care as

usual

index of life

quality (MILQ)

EQ-5D

Beck Depression

Inventory

1year Multidimensional

62.0±13.77

Short-stay

intensive care

group:

61.8±10.67

State-Trait Anxiety

Inventory

No. of

patients

64 65.2±9.3 3months SF-12 Patients reported

baseline Age of patients

Prospective

cohort study

Consecutive

patients undergoing

Sandau,

Author, year,

2008 [35]

Ref Intervention Study type

CABG n=64

226 62.9±9.5 6months SF-36 Elevated

Prospective

cohort study

Elective CABG

patients n=226

Tully, 2009

[36]

410 Control group:

Randomised

clinical

equivalence

trial

CABG patients

undergoing

short-stay intensive

care (8h intensive

care) n=201

Van

Mastrigt,

2010 [37]

CABG patients

control subjects

(overnight intensive

care stay) n=207

Y. S. Abdullahi et al.

Physical

Nil ********

component

improved Quality score

Coronary artery

HRQOL

instruments Conclusion

1year Seattle Angina

Follow-up duration

(mean)

bypass grafting

with the radial

artery lasts

approximately

31minutes

longer than with

Questionnaire and

Health Utility

Index

Group:

62±8

Radial Artery

group:

61±8

the saphenous

vein. However,

costs and the

quality of life

were not

statistically

different

No. of

patients

Table 3.2 (continued)

733 Saphenous Vein

baseline Age of patients

Multicentre

randomised

Patients undergoing

isolated CABG,

Wagner,

Author, year,

2011 [38]

Ref Intervention Study type

control trial

radial artery group

n=366

Patients undergoing

isolated CABG,

saphenous vein

group n=367

3 What Factors Predict an Improved Quality of Life Outcome Following Coronary Artery Bypass Graft…

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(continued)

Physical

component

improved Quality score

Follow-up

duration (mean) HRQOL instruments Conclusion

CABG better **********

symptomatic relief

and improvement in

QoL after one year

and was also

1year SF-36, DASI, RDS CABG gave greater

Nil ************

CABG plus medical

associated with a

higher rate of

complete

therapy produced

revascularisation

Cardiomyopathy

36months The Kansas City

clinically important

improvements in

several health status

domains compared

with medical therapy

alone over 36months

Cardiac Self-

Efcacy

Questionnaire

Questionnaire,

SF12, SF36

EuroQol-5D

*********

During the rst

postprocedure

year, patients’

angina burden

and physical

limitations were

stent-assisted PCI

dramatically

improved cardiac-

related health status

in patients with

1year SAQ Both CABG and

************

alleviated to a

greater extent

with CABG

No difference in

Physical

multivessel disease at

6- and 12-month

follow-up

three-vessel or left

SF-36, SAQ Among patients with

1,6,12,36 and

60months

component at

1year but

signicantly

better at 5years

in favour of

CABG

main coronary artery

disease, there was

greater relief from

angina after CABG

than after PCI at 6

and 12months

No. of patients at

baseline

Medical (n=127)

Study

type

RCT CABG (n=174)

CABG vs Medical

(elderly)

Author, year,

Ref Intervention

Kaiser etal.,

Table 3.3 RCT trial studying CABG and QoL

2004 [39]

Medical (602)

RCT CABG (n=610)

CABG vs Medical

(High risk IHD

with LV

dysfunction and

multivessel

disease)

Mark etal.,

2014 [26]

PCI (n=488)

RCT CABG (n=500)

CABG vs PCI

(SoS)

Zhang etal.,

2003 [40]

PCI (n=903)

RCT CABG (n=897)

CABG vs PCI

(SYNTAX)

Abdalla etal.,

2013 [41]

Y. S. Abdullahi et al.

Physical

component

improved Quality score

Follow-up

duration (mean) HRQOL instruments Conclusion

***********

CABG

continued to

demonstrate

better outcomes

on the physical

comparisons

generally favored

CABG between

6months and 2years,

SAQ, RDS Between group

1, 6 and

12months.

Yearly

thereafter

limitations SAQ

subscales

through 2 to

5years of

but the observed

differences were

small. Beyond

2years, there were

follow-up.

no consistent

differences between

the 2 treatment

strategies

*************

Male patients

coped better in

terms of physical

functioning

compared with

HRQoL and early

return to work

regardless of the

technique

CCS, SF-36 Improvement in

At baseline,

six and

12months

postoperative

*************

females

No difference in

change in SF-36

Physical

component

OPCAB patients did

not show fewer

cognitive decits or

greater improvement

in HRQoL than

SF-36, CVLT, TMT,

DigSymb, The

National Adult

Reading Test

At baseline,

before

discharge,

6months

postoperative

*************

No difference in

change in SF-36

Physical

component

CABG patient

Using OPCAB

instead of CABG has

no effect on 5-year

cognitive or HRQoL

A battery of 10

neuropsychological

tests, SF-36,

EuroQoL

At baseline,

three and

12months,

and 5years

surgery

outcome after

postoperative

No. of patients at

Study

Author, year,

Table 3.3 (continued)

baseline

PCI (n=953)

type

RCT CABG (n=947)

CABG vs PCI

(FREEDOM)

Ref Intervention

Farkouh etal.,

2012 [42]

OPCAB (n=105)

RCT CABG (n=97)

CABG vs

OPCABG

QoL post CABG: CABG vs OPCABG

Noqueira

etal., 2008

[43]

OPCAB (n=30)

Controls (n=50)

RCT CABG (n=36)

CABG vs

OPCABG

Tully etal.,

2008 [44]

OPCAB (n=123)

RCT CABG (n=117)

CABG vs

OPCABG

Van Dijk etal.,

2007 [45]

3 What Factors Predict an Improved Quality of Life Outcome Following Coronary Artery Bypass Graft…

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(continued)

Physical

component

improved Quality score

Follow-up

duration (mean) HRQOL instruments Conclusion

*********

No difference in

change in SF-36

Physical

component

CABG results in

similar HRQoL

outcome 6 and

18months after

SF-36 OPCABG and

Six and

18months

postoperative

*************

No difference in

change in SF-36

Physical

component

elderly moderate-to-

high-risk patients, but

surgery

SF-36, MDI-scale OPCAB and CABG

At baseline,

there was no

improved HRQoL in

3months

postoperative

*************

No difference in

change in

clinically relevant

difference in HRQoL

between the groups

Using OPCAB

showed a trend for

A battery of 11

neuropsychological

At baseline,

6weeks and

WHOQOL

Physical

component

better HRQoL scores

compared to

CABG.Better

neurocognitive

function was seen in

patients who

underwent OPCAB

tests, WHOQOL

6months

postoperative

************

No difference in

change in SF-36

Physical

component

No signicant

differences in

HRQoL were found

cross-sectionally or

longitudinally

CCS, SF-36,

QOLS-N, Hospital

Anxiety and

Depression Scale

At baseline, 3,

6, and

12months

postoperative

*************

No difference in

change in SF-36

Physical

component

HRQoL at 30days

and one year after

surgery was similar

in CAGB and

OPCAB groups

CCS, NYHA,

SF-36, EuroQoL

At baseline,

4–6weeks,

6months and

1year

postoperative

No. of patients at

baseline

OPCAB (n=123)

Study

type

RCT CABG (n=117)

CABG vs

OPCABG

Author, year,

Ref Intervention

Motellebzadeh

etal., 2006

[46]

OPCAB (n=54)

RCT CABG (n=55)

CABG vs

OPCABG

(elderly)

Jensen etal.,

2006 [47]

OPCAB (84)

RCT CABG (n=84)

CABG vs

OPCABG

Al Ruzzeh

etal., 2006

[48]

OPCAB (n=60)

RCT CABG (n=60)

CABG vs

OPCABG

Mathisen

etal., 2005

[49]

OPCAB (n=98)

RCT CABG (n=99)

CABG vs

OPCABG

Puskas etal.,

2004 [50]

Y. S. Abdullahi et al.

Physical

component

improved Quality score

Follow-up

duration (mean) HRQOL instruments Conclusion

**************

Physical

function

improved

signicantly

between baseline

and all points of

follow up

groups post-

operatively compared

to pre-operatively.

improved

signicantly in both

8years SF-36 HRQoL SF-36 scores

On-Pump patients

************

(3months,

12months,

8years) across

both groups.

No difference in

had a greater social

function score

compared to

off-pump

counterparts

1year SAQ, VR-36 low-to-moderate risk

QoL

measurement

male veterans

undergoing CABG

surgery with

off-pump versus

on-pump technique

had similar 3-month

and 1-year HRQL

outcomes

***********

SF-36 Physical

component

showed

signicant

improvement at

A physiotherapy-

supervised intensity

walking program

improves physical

capacity at hospital

discharge

6MWA, SF-36, VC

At baseline, at

discharge, and

four weeks

after discharge

No. of patients at

Study

Author, year,

Table 3.3 (continued)

baseline

OPCABG n=61

type

RCT CABG n=59

CABG vs

OPCABG

Ref Intervention

Østergaard

etal., 2015

Elderly

[32]

OPCABG n=1104

RCT CABG n=1099

CABG vs

OPCABG

Bishawi etal.

2013, [51]

(ROOBY)

(n=32); Walking

exercise PT

(n=31); Walking/

breathing exercise

PT (n=30)

RCT Standard PT

CABG inpatient:

physiotherapy-

supervised

walking program,

with or without

musculoskeletal

and respiratory

exercises

QoL post CABG: Further intervention

Hirschhorn

etal., 2008

[52]

3 What Factors Predict an Improved Quality of Life Outcome Following Coronary Artery Bypass Graft…

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(continued)

Physical

component

improved Quality score

Follow-up

duration (mean) HRQOL instruments Conclusion

************

Intervention

showed

signicant

improvement in

the Physical

prevention (i.e.,

counseling,

blood-pressure

control, medication

SF-36, CROQ Enhanced risk factor

At baseline, 3

and 6months

postoperative

***********

QoL only in the

SF36

Compared to the

general

population,

optimized) did not

improve post-CABG

HRQoL

markedly over time

in both groups, but

SF-36, SAQ HRQoL improved

At baseline,

6weeks and

6months

signicant

differences were

found for the

SF-36 subscales:

role physical,

no signicant effects

of the HBIP were

found

postoperative

**********

role emotional

and bodily pain

No difference in

change in SF-36

Physical

differences in

HRQoL, unexpected

SF-36, MSAS No signicant

Five weeks

after discharge

************

component

contacts with the

healthcare system, or

No difference in

change in SF-36

symptom distress

between groups

Hypothermic

conditions during

CES-D, STAI, MOS

DASI, QARS-IADL

At baseline,

6weeks, and

**************

Physical

component

Improvement in

the physical

component was

observed

CABG are associated

with higher levels of

emotional distress

Enhanced

intervention during

the waiting period for

CABG improves

SF-36

6months

postoperative

SF-36, ISEL, STAI,

HSUQ

One week

before

surgery, at

baseline,

functional abilities

and HRQoL

postoperatively

6weeks, and

6months

postoperative

No. of patients at

baseline

risk factor

prevention (n=94);

Study

type

RCT CABG+enhanced

Enhanced risk

factor prevention

Author, year,

Ref Intervention

Goodman

etal., 2008

CABG only (n=94)

[53]

CABG/HBIP

(n=93)

RCT CABG (n=92)

Home based

intervention

program

Lie etal.,

2009, [54]

postoperative

support after CABG

(n=92); Usual care

after CABG (n=92)

RCT Advanced

Advanced

postoperative

support after

CABG

Tranmer etal.,

2004 [55]

CABG (n=115);

hypothermic CABG

(n=111)

RCT Normothermic

Normothermia vs

Hypothermia

Khatri etal.,

2001 [56]

RCT Enhanced

Multi dimensional

Arthur etal.,

intervention before

CABG (n=123);

Normal intervention

before CABG

(n=123)

preoperative

intervention:

exercise,

education and

social support

2000 [57]

Y. S. Abdullahi et al.

Physical

component

improved Quality score

Follow-up

duration (mean) HRQOL instruments Conclusion

**************

Improvement in

the physical

component was

observed

Patients who received

peer support in

hospital at the time of

CABG experienced

improvements in

physical and mental

SF-36, CES-D,

SCL-90R, self-rated

health assessment

At baseline, 1,

6, and

12months

postoperative

*********

Reduced

physical

functional

component

well-being

had lower scores on

scales measuring

psychological

SF-36, NYHA Patients with ICDs

Six months

postoperative

************

Obesity and

Euroscore were

well-being,

perception of health,

and emotional role

functioning

after both modes of

SF-36 HRQoL in patients

Pre-op and

12months

independent

predictors of the

Physical

component

revascularization

signicantly

improved after

12months in all

domains.

*************

Patients in the

CABG alone

group had the

lowest scores for

the role-physical

of AF during CABG

surgery improves

QoL in all physical

health domains of the

SF-36 Effective elimination

Pre-opo,

1year and

2years

post-op

functioning,

vitality, and

social

functioning

SF-36

domains

No. of patients at

Study

Author, year,

Table 3.3 (continued)

baseline

and after CABG

(n=100); Controls

(n=90)

type

RCT Peer support before

Supportive

intervention

Ref Intervention

Thoits etal.,

2000 [58]

(n=446); No ICD

after CABG

(n=454)

RCT ICD after CABG

Effect of empiric

ICD post CABG

in patients with an

increased risk of

arrhythmic

cardiac death

Namerow

etal., 1999

[59]

Hybrid (n=98)

RCT CABG (n=102)

CABG vs Hybrid

(POLMIDES)

Gierszewska

etal., 2018

[60]

CABG+PVI

(n=31) or CABG

+MiniMaze (n=30)

RCT CABG (n=34)

CABG vs

CABG+AF

ablation

Chernyavskiy

etal., 2016

[61]

3 What Factors Predict an Improved Quality of Life Outcome Following Coronary Artery Bypass Graft…

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control and intervention groups varied between each study making statistical analysis nonfeasible. Population groupings by. pre-operative comorbidity, included diabetic status [30], angina status [11] and peri-operative MI [19]. The main patient demographics used as a grouping method were age [27] and gender [13]. Groupings by operative technique included on-pump vs offpump [21, 32] and total arterial revascularisation versus saphenous vein combinations [14].

Patient ages ranged from 39 to 88.8years and the included studies sample size ranged between 48 to 2000. The procedures undergone by these patients varied in terms of incision method and operation type; open sternotomy was noted as the preferred choice over minimal access. All studies had a follow-up period ranged from 3months to 15years.

Quality ofStudies

Table 3.2 highlights the quality score achieved by each study according to the modied NewcastleOttowa scale. The scores ranged from 2 to 14, highlighting that the quality of studies was skewed negatively. This reects the clarity in study design and outcomes reported.

HRQOL Tools

A total of 45 different health related quality of life measurement tools was applied in almost all the articles individually apart from few studies that co-applied two or more tools in their study group. Majority of the studies utilised SF-36 to assess and measure quality of life (Table3.2).

Outcomes

Most of the studies reported improved HRQOL following CABG compared to baseline. Whilst not the focus of the studies, outcomes including in-hospital mortality, complications and prolonged length of stay were reported. However, studies failed to report on common endpoints

which limited formal meta-analysis. This limited our interpretation of baseline predictors for HRQOL and a cut-off value that accurately measures CABG surgery consequences in elderly patients.

Discussion

In our present analysis, we conducted a systematic review of 54 studies assessing quality of life after coronary artery bypass graft (CABG) surgery. Whilst there was notable variability amongst the studies, our review has found that, overall, CABG surgery confers not only an improved long-term survival, but an improved physical and mental well-being as seen from a variety of scoring tools indicating a better health related quality of life (HRQOL) after CABG surgery.

In the modern era, the rise of percutaneous revascularisation over surgery makes the issue of HRQOL ever more important, and raises several questions of the overall risk gain benet ratio, other than mortality as a single objective end point. The impact of the surgical burdens of a median sternotomy, cardiopulmonary bypass and intensive care unit stay on patients’ HRQOL post-surgery in the short and longer term, especially compared to PCI, may reect this evolution. Moreover, perhaps not unexpectedly, most of the current evidence base assesses CABG from a technical standpoint, with outcomes moreoften- than not being mortality as well as traditional measures of morbidity. This is juxtaposition to the amount of literature available on the HRQOL outcomes following CABG, which is sparse; our initial search identied only 40 articles. Comparatively a crude PubMed search for ‘outcomes’ and ‘coronary artery bypass grafts’ identied thousands of articles.

Patients requiring CABG undergo a signicant amount of physical and psychological stress in the perioperative process and the rehabilitation postsurgery. The impact on physical competency post sternotomy, post-surgical pain, and the psychosocial stresses associated with the recovery process, impedes gains in quality of life perceived by patients or, worse, a decline in quality of life post

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