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. 2024 Jan-Feb;20(1):9–19. doi: 10.48305/arya.2024.42234.2926

Is cardiac rehabilitation after pci as effective as cabg? The first experience from the eastern mediterranean region cardiac rehabilitation registry

Masoumeh Sadeghi 1, Erfan Sheikhbahaei 2, Dominique Hansen 3,4,5, Razieh Hassannejad 6, Sina Rouhani 1, Mohammad Mahdi Hadavi 6, Safoura Yazdekhasti 1, Amir Behfar 7, Hamidreza Roohafza 6
PMCID: PMC11331554  PMID: 39165855

Abstract

BACKGROUND:

The effectiveness of cardiac rehabilitation (CR) programs following either percutaneous coronary intervention (PCI) or coronary artery bypass grafting (CABG) has been separately studied. Few studies have compared the effects of similar CR programs between PCI and CABG. This study aimed to compare the effects of CR in patients recruited following either PCI or CABG on coronary heart disease risk factors, psychological variables, and functional capacity.

METHODS:

For this retrospective study, the documents of the CR program registry of the Isfahan Cardiovascular Research Institute were reviewed from 2008 to 2021. Patients with ischemic heart disease undergoing PCI or CABG were enrolled in an 8-week exercise-based cardiac rehabilitation program. Demographics, smoking status, clinical data, echocardiographic parameters, laboratory data, functional capacity, and psychological status were assessed.

RESULTS:

Patients who underwent CABG (n=557) were more likely to be referred to CR than those who underwent PCI (n=440). All variables changed significantly after the CR program compared to their baseline value in both the PCI and CABG groups. However, low-density lipoprotein and total cholesterol levels, peak systolic blood pressure, and resting and peak diastolic blood pressure did not change in any of the groups, and fasting blood sugar (p=0.01) and triglyceride (TG) (p=0.01) levels significantly decreased only in the PCI group. Between-group comparisons indicated that after adjustment, no significant difference was observed between the PCI and CABG groups except for TG, which was significantly reduced in the PCI group (p=0.01).

CONCLUSION:

The CR program was equally effective in patients who underwent either PCI or CABG.

Key Words: Cardiac Rehabilitation, Percutaneous Coronary Intervention, Coronary Artery Bypass Grafting, Coronary Heart Diseases, Psychological Factors, Risk Factor

Introduction

Cardiovascular diseases, which are the leading cause of death globally, have several modifiable risk factors1,2 and can be managed and intervened upon by comprehensive exercise-based rehabilitation programs3. Cardiac rehabilitation (CR) programs have been introduced to patients following coronary events to facilitate lifestyle changes4-6. Indeed, CR has significant positive effects on the functional capacity, lipid profile, glycemic control, echocardiographic indexes, smoking behavior, and blood pressure of patients6-8. These programs can also enhance the quality of life, modify psychological factors, and reduce mortality and readmission rates9,10. Although CR is highly recommended for all patients with coronary artery disease, referral to and participation in CR is globally low11-13.

There are extensive studies on the effectiveness of CR after coronary artery bypass grafting (CABG), leading to an accumulation of evidence in favor of CR following this intervention4. Revascularization in patients with coronary artery diseases is also treated with less invasive procedures like percutaneous coronary intervention (PCI). Numerous studies have evaluated the impacts of CR in PCI only10-14; however, there is a lack of evidence from the Middle-Eastern region in this regard. Furthermore, no study has ever compared the effectiveness of CR after PCI to that of CABG. Therefore, the authors aimed to compare the impact of phase-II comprehensive CR after PCI vs. CABG on coronary heart disease risk factors, psychological variables, and functional capacity of the CR registry in the Eastern Mediterranean region. The authors hypothesize that if the value of CR after PCI is not more than that of CABG, it is not less than that, and both PCI and CABG patients will benefit from CR to an equal magnitude.

Methods

Study design

For this retrospective study, the CR program registry of the Cardiac Rehabilitation Research Center of the Cardiovascular Research Institute (a WHO-collaborating center in EMRO) was searched and reviewed from January 2008 to December 2021. All patients with ischemic heart disease who were admitted for either PCI or CABG were advised to participate in this hospital-based CR program. Before being discharged, an invitation card was given to them, which needed to be validated by their cardiologist or surgeon before participating in the program. The inclusion criteria were all registered patients who had undergone either PCI or CABG for the first time, completed the CR program as scheduled, and answered all the questionnaires. The exclusion criteria included the following: patients with serious medical conditions (e.g., cerebral vascular attacks, chronic kidney disease, cirrhosis, and chronic obstructive sleep apnea), patients who couldn’t tolerate physical activity sessions, > 20% missing data in the medical documents or questionnaires, a previous history of PCI or CABG, and missing two or more CR program sessions.

Cardiac rehabilitation program:

CR was recommended to every patient with any indications of CR. This 8-week exercise-based CR program included both physical exercise and educational sessions. The physical exercise sessions were offered three times a week for eight weeks (24 sessions in total) and supervised by a trained sports physician. The eight lecture-based educational sessions for controlling stress, anxiety, and depression, as well as for quitting smoking, were led by a trained psychologist. The sessions on following a healthy lifestyle and nutrition plan were led by a trained dietician. The patients were contacted regularly before their sessions by the center secretary and reminded of the scheduled classes.

Assessments

A checklist of demographic variables (age and sex), smoking status (current, former, and never), physical activity level, laboratory data, cardiac function test results, and psychological status was used at the time of registration (within one week before starting the program), and was repeated within one week of completing the program.

To assess the physical activity level, the Persian validated long-form version of the International Physical Activity Questionnaires (IPAQ) was used15.IPAQ is a 7-day recall questionnaire that measures time spent per week on vigorous activity, moderate activity, and walking. Briefly, IPAQ assesses physical activity undertaken across a comprehensive set of domains (work, transportation, housework, and leisure time). Activity is then calculated as the total time (in minutes) spent in three activity categories. The total time in each category is then weighted by a Metabolic Equivalent of Tasks (METs). According to the reported METs, subjects were categorized into three levels of activity: walking, moderate, and vigorous15.

Fasting blood samples were obtained before starting and after completing the program. All the samples were taken in the central laboratory at the center by the same team. Fasting blood glucose (FBS) and a lipid profile (triglyceride (TG), total cholesterol (TC), high-density lipoprotein cholesterol (HDL-C), and low-density lipoprotein cholesterol (LDL-C)) were recorded.

Echocardiography was scheduled for all patients before starting and after completing the CR. All echocardiographies were performed in the left lateral decubitus position with the Philips IE33 ultrasound machine and interpreted by an echocardiologist under standard protocols to obtain the left ventricular ejection fraction (EF)16.

The computer-controlled treadmill exercise test (Stress Test System, AST-3000, AVECINA Company, Iran) was used to evaluate functional capacity. The resting heart rate (HR), systolic, and diastolic blood pressure (SBP and DBP, respectively) were measured manually under the standard protocol before the exercise by an experienced exercise test room nurse. The intensity of the exercise test was scheduled with the graded multi-stage maximal symptom-limited Bruce protocol17,18, which was continued until physical exhaustion or serious signs/symptoms occurred. The HR, SBP, and DBP were measured once at every stage, at peak exercise, and twice during the recovery phase. After completion, test duration, cardiorespiratory function in METs (derived from the walking speed and slope), and electrocardiography were extracted from the program. The final result of the exercise test was interpreted by a cardiologist and categorized as positive, negative, or undetermined/unidentifiable.

To assess psychological status, the authors used the validated Persian versions of the questionnaires for anxiety19, depression20, general quality of life (QoL)21, and health-related quality of life (HR-QoL)22.

Anxiety was evaluated with the 20-item Zung’s self-rating anxiety scale (SAS) questionnaire23 with scores ranging from normal to mild (20-44), moderate (45-59), severe (60-74), and very severe (75 and above).

The level and score of depression were assessed using the Beck depression inventory (second edition) questionnaire (BDI-II), which consists of 21 questions20 with scores of low (0-10), mild (11-16), moderate (17-30), and high (31 and above).

The SF-36 questionnaire was utilized by the authors to evaluate the general aspects of QoL21. This questionnaire has two general domains, namely physical and mental health, each with four subdomains. HR-QoL in cardiac disease was evaluated using the 27-item MacNew questionnaire22 with questions classified into physical, emotional, and social domains.

Statistical Analysis

The authors carried out all analyses with IBM SPSS software version 20.0. Categorical variables are expressed as numbers and percentages, while quantitative variables are expressed as mean and standard deviation. The Kolmogorov-Smirnov test was used to verify the normality assumption. For quantitative variables, a baseline measurement was assessed by an independent t-test or Mann–Whitney test (if the normality assumption was not met). Categorical variables were compared using the Chi-square test. Bonferroni correction was applied to determine the significance of any differences. Within-group comparisons were assessed by paired t-tests for normally distributed variables or Wilcoxon tests for non-normally distributed variables. Analysis of covariance (ANCOVA) was used to evaluate between-group comparisons. Variables that were significantly different at baseline or were confounders were also adjusted in ANCOVA. If the heterogeneity of variance was not met, a logarithmic transformation was applied. P-values < 0.05 (two-tailed) are considered statistically significant.

Results

The CR program was conducted more frequently following CABG than PCI (n=557 vs. n=440 patients, respectively). Among these patients, male participation was higher than female, but there was no significant difference between the two genders (426 (76.48%) in CABG and 316 (71.81%) in PCI, p=0.1). The authors found that CABG patients were significantly older than the PCI patients (58.94±8.85 vs. 57.72±9.79 years, p= 0.02). 111 documents were excluded from the secondary analysis due to missing data after CR assessments.

CABG participants had significantly higher LDL-C (p<0.0001) and TC (p<0.0001) levels compared to PCI. However, the mean EF (p=0.01), exercise test METs (p=0.019), anxiety (p<0.0001), and depression (p<0.0001) scores were significantly higher in PCI (Table 1).

Table 1.

Cardiac rehabilitation participants' baseline characteristics before the program

Variables Total
(n=997) 		PCI
(n=440) 		CABG
(n=557) 		P
Smoking
n, (%) 		Never 761 (76.32) 335 (76.13) 426 (76.48) 0.61
Current 93 (9.32) 45 (10.22) 48 (8.61)
Past 143 (14.34) 60 (13.63) 83 (14.9)
Physical Activity (MET.min/week)
Walking 2025.87±2141.84 1885.80±2123.94 2212.63±2157.77 0.03
Moderate 1896.29±3832.13 2391.70±4670.37 1235.73±2118.79 <0.0001
Vigorous 1140.09±4322.76 824.88±2551.24 1560.36±5894.96 0.86
Total 9265.11±5367.67 9451.47±5497.35 9016.25±5195.70 0.52
Lab Data
Fasting Blood Sugar (mg/dL) 111.08±36.63 112.08±40.39 110.30±33.41 0.80
Triglyceride (mg/dL) 165.54±91.49 163.87±90.98 166.85±91.95 0.38
Low-density lipoprotein (mg/dL) 92.85±35.57 86.66±32.26 97.78±37.30 <0.0001
High-density lipoprotein (mg/dL) 39.54±9.19 38.92±8.58 40.03±9.62 0.14
Total cholesterol (mg/dL) 167.03±45.85 160.33±44.43 172.31±46.29 <0.0001
Cardiac Function tests
Ejection fraction (%) 51.21±11.27 52.02±11.87 50.57±10.73 0.01
Treadmill
Exercise
stress
test 		Resting HR (bpm) 79.78±16.03 76.69±15.00 82.23±16.40 <0.0001
Peak HR (bpm) 125.87±23.85 122.52±23.19 128.53±24.05 <0.0001
Resting SBP (mmHg) 116.99±17.66 117.07±16.48 116.94±18.57 0.83
Peak SBP (mmHg) 131.84±22.53 129.35±23.43 133.39±21.85 0.01
Resting DBP (mmHg) 72.25±10.24 72.72±9.68 71.86±10.67 0.20
Peak DBP (mmHg) 77.43±10.52 76.84±10.98 77.79±10.23 0.40
Test Duration (min) 14.41±4.94 14.36±4.64 14.45±5.18 0.67
METs 8.49±3.06 8.79±3.32 8.25±2.81 0.01
Result Negative 700 (70.21) 312 (70.9) 388 (69.65) 0.01a
Positive 100 (10.03) 31 (7.07) 69 (12.38)
UD 197 (19.75) 97 (22.04) 100 (17.95)
Psychological status
Anxiety
Level 		Normal -mild 711 (71.31) 288 (65.45) 423 (75.94) <0.0001b
Moderate 231 (23.16) 123 (27.95) 108 (19.38)
Severe 51 (5.11) 26 (5.9) 25 (4.48)
Very severe 4 (0.4) 3 (0.68) 1 (0.17)
Anxiety Score 40.34±10.61 41.89±11.11 39.09±10.02 <0.0001
Depression
level 		Low 735 (73.72) 293 (66.59) 442 (79.35) <0.0001c
Mild 118 (11.83) 65 (14.77) 53 (9.51)
Intermediate 90 (9.02) 52 (11.81) 38 (6.82)
High 54 (5.41) 30 (6.81) 24 (4.30)
Depression Score 11.19±9.14 12.50±10.06 10.13±8.18 <0.0001
General
Quality of life 		Physical functioning 59.05±23.33 60.78±24.79 56.96±21.28 0.02
Role-Health 35.31±37.25 36.92±37.98 33.36±36.31 0.26
Body pain 63.47±26.24 64.22±26.33 62.56±26.14 0.45
General health 59.14±19.07 58.95±18.96 59.38±19.22 0.82
Energy/Fatigue 56.95±22.10 56.45±22.64 57.57±21.45 0.42
Social functioning 67.46±25.93 68.50±26.36 66.19±25.39 0.18
Role emotional 53.75±40.93 54.99±41.61 52.24±40.10 0.37
Emotional Well being 66.11±22.30 66.57±21.79 65.55±22.93 0.64
Health-related Quality of life Physical 4.75±1.08 4.69±1.10 4.79±1.07 0.28
Social 4.81±1.08 4.78±1.06 4.84±1.09 0.46
Emotional 4.75±0.93 4.64±0.86 4.83±0.98 0.01
Open in a new tab

PCI, percutaneous coronary intervention; CABG, coronary artery bypass grafting surgery; UD, undetermined; HR,

heart rate;SBP, systolic blood pressure; DBP, diastolic blood pressure

a According to Bonferroni method analysis, this significant P value was seen in two situation: when comparing negative

group with positive group and when comparing group "other" with positive group.

b According to Bonferroni method analysis, this significant P value was seen when comparing the normal-mild group with

moderate group.

c According to Bonferroni method analysis, this significant P value was seen when comparing group "low" with other groups.

As shown in Table 2, all variables underwent significant changes after the CR program compared to their baseline value in either the PCI or CABG group. However, LDL-C and TC levels, peak SBP, and resting and peak DBP remained unchanged in all groups. Only in the PCI group did FBS (p=0.01) and TG (p=0.01) levels significantly decrease.

Table 2.

Comparison of variables before and after the program in each group

Variables PCI CABG
Before After P Before After P
Smoking Never 335 (76.13) 335 (76.13) <0.0001a 426 (76.48) 426 (76.48) <0.0001a
Current 45 (10.22) 12 (2.72) 48 (8.61) 16 (2.87)
Past 60 (13.63) 93 (21.13) 83 (14.9) 115 (20.64)
Physical Activity (MET.min/week)
Walking 1885.80±2123.94 2273.18±1956.64 <0.0001 2212.63±2157.77 3094.22±2797.82 <0.0001
Moderate 2391.70±4670.37 3399.20±3059.22 <0.0001 1235.73±2118.79 3080.00±3686.04 <0.0001
Vigorous 824.88±2551.24 2346.86±9522.90 <0.0001 1560.36±5894.96 1293.04±4097.96 0.16
Total 9451.47±5497.35 11179.09±5078.57 <0.0001 9016.25±5195.70 11218.78±5275.16 <0.0001
Lad Data
Fasting Blood Sugar (mg/dL) 112.08±40.39 107.31±30.56 0.01 110.30±33.41 108.97±33.44 0.84
Triglyceride (mg/dL) 163.87±90.98 144.94±65.72 0.01 166.85±91.95 156.97±76.48 0.66
Low-density lipoprotein (mg/dL) 86.66±32.26 84.48±27.30 0.81 97.78±37.30 94.38±31.69 0.37
High-density lipoprotein (mg/dL) 38.92±8.58 39.89±10.46 0.03 40.03±9.62 41.41±9.77 0.01
Total cholesterol (mg/dL) 160.33±44.43 154.68±36.03 0.26 172.31±46.29 167.50±37.84 0.44
Cardiac Function tests
Ejection fraction (%) 52.02±11.87 53.79±10.51 <0.0001 50.57±10.73 53.96±9.59 <0.0001
Treadmill
Exercise
stress
test 		Resting HR (bpm) 76.69±15.00 74.47±14.42 0.02 82.23±16.40 77.13±15.84 <0.0001
Peak HR (bpm) 122.52±23.19 131.36±23.68 <0.0001 128.53±24.05 130.03±24.12 0.01
Resting SBP (mmHg) 117.07±16.48 113.70±16.12 0.02 116.94±18.57 116.05±17.02 0.04
Peak SBP (mmHg) 129.35±23.43 129.35±21.49 0.85 133.39±21.85 134.68±25.45 0.53
Resting DBP (mmHg) 72.72±9.68 71.42±9.05 0.48 71.86±10.67 72.11±9.97 0.20
Peak DBP (mmHg) 76.84±10.98 76.82±10.41 0.47 77.79±10.23 78.42±15.13 0.13
Test Duration (min) 14.36±4.64 18.09±4.95 <0.0001 14.45±5.18 17.73±4.76 <0.0001
METs 8.79±3.32 11.93±3.70 <0.0001 8.25±2.81 10.90±3.07 <0.0001
Result Negative 312 (70.9) 379 (86.13) <0.0001b 388 (69.65) 474 (85.09) <0.0001b
Positive 31 (7.07) 16 (3.63) 69 (12.38) 20 (3.59)
UD 97 (22.04) 45 (10.22) 100 (17.95) 63 (11.31)
Psychological status
Anxiety
Level 		Normal -mild 288 (65.45) 342 (77.72) <0.0001c 423 (75.94) 459 (82.4) <0.0001c
Moderate 123 (27.95) 83 (18.86) 108 (19.38) 93 (16.69)
Severe 26 (5.9) 15 (3.4) 25 (4.48) 5 (0.89)
Very severe 3 (0.68) 0 (0) 1 (0.17) 0 (0)
Anxiety Score 41.89±11.11 39.72±11.13 <0.0001 39.09±10.02 38.02±9.78 0.000
Depression
level 		Low 293 (66.59) 357 (81.13) <0.0001d 442 (79.35) 496 (89.04) <0.0001d
Mild 65 (14.77) 43 (9.77) 53 (9.51) 27 (4.84)
Intermediate 52 (11.81) 29 (6.59) 38 (6.82) 25 (4.48)
High 30 (6.81) 11 (2.5) 24 (4.30) 9 (1.61)
Depression Score 12.50±10.06 10.31±9.16 <0.0001 10.13±8.18 8.18±7.34 <0.0001
General
Quality of life 		Physical functioning 60.78±24.79 70.16±20.86 <0.0001 56.96±21.28 68.13±20.93 <0.0001
Role-Health 36.92±37.98 55.43±39.35 <0.0001 33.36±36.31 51.03±38.60 <0.0001
Body pain 64.22±26.33 74.39±22.80 <0.0001 62.56±26.14 73.58±21.67 <0.0001
General health 58.95±18.96 64.03±18.74 <0.0001 59.38±19.22 64.38±17.82 <0.0001
Energy/Fatigue 56.45±22.64 64.16±20.19 <0.0001 57.57±21.45 62.65±20.56 <0.0001
Social functioning 68.50±26.36 77.60±22.02 <0.0001 66.19±25.39 76.21±22.63 <0.0001
Role emotional 54.99±41.61 64.86±38.30 <0.0001 52.24±40.10 64.66±37.56 <0.0001
Emotional Well-being 66.57±21.79 71.77±19.56 <0.0001 65.55±22.93 69.74±21.04 <0.0001
Health related
Quality of life 		Physical 4.69±1.10 5.25±1.00 <0.0001 4.79±1.07 5.27±0.93 <0.0001
Social 4.78±1.06 5.35±1.01 <0.0001 4.84±1.09 5.38±0.96 <0.0001
Emotional 4.64±0.86 4.88±0.80 <0.0001 4.83±0.98 5.07±0.86 <0.0001
Open in a new tab

PCI, percutaneous coronary intervention; CABG, coronary artery bypass grafting surgery; UD, undetermined; HR, heart rate; SBP, systolic blood pressure; DBP, diastolic blood pressure

a Bonferroni correction showed significant difference when comparing the "never" group with either "smoker" or "past" group.

b Bonferroni correction showed significant difference when comparing the "negative" group with either "positive" or "other" group.

c Bonferroni correction showed significant difference when comparing the "normal-mild" group with either "moderate" or "severe" group.

d Bonferroni correction showed significant difference when comparing the "low" group with either "mild", "intermediate" or, "high" group.

Between-group comparisons, after full adjustment, indicated no significant change after the CR program between the PCI and CABG groups, except for TG (Table 3). The authors observed a significant reduction in TG after the CR program in patients with PCI compared to those with CABG.

Table 3.

Comparison of delta difference of each variable between the groups

Variables Total PCI
[After-Before] 		CABG
[After-Before] 		P *
Quit Smoking n, (%) 65 (6.5) 33 (7.5) 32 (5.7) 0.10
Physical Activity (MET.min/week)
Walking 536.37±2672.43 287.84±2533.96 834.62±2810.94 0.15a
Moderate 1421.28±4710.96 1054.29±5385.52 1861.66±3718.88 0.86
Vigorous 964.85±7651.86 1533.70±9422.53 282.24±4672.63 0.26
Total 2117.79±6696.30 1995.71±6610.77 2262.70±6820.68 0.58
Lab Data
Fasting Blood Sugar (mg/dL) -2.66±28.48 -4.81±28.64 -0.88±28.26 0.31
Triglyceride (mg/dL) -7.96±74.78 -11.76±61.54 -4.81±84.12 0.01a
Low-density lipoprotein (mg/dL) -1.26±30.88 -0.47±27.43 -1.92±33.54 0.37
High-density lipoprotein (mg/dL) 1.01±9.11 1.01±8.13 1.01±9.86 0.85
Total cholesterol (mg/dL) -2.57±38.10 -3.48±37.13 -1.82±38.92 0.11
Cardiac Function tests
Ejection fraction (%) 2.51±6.74 2.03±6.47 2.93±6.94 0.14
Treadmill
Exercise
stress
test 		Resting HR (bpm) -3.31±14.42 -1.95±14.87 -4.46±13.95 0.12
Peak HR (bpm) 5.83±23.83 8.96±25.74 3.15±21.75 0.06
Resting SBP (mmHg) -2.30±17.96 -2.60±16.60 -2.04±19.04 0.31
Peak SBP (mmHg) 1.03±22.37 0.01±21.97 1.70±22.64 0.81
Resting DBP (mmHg) -0.70±10.73 -0.66±10.71 -0.73±10.77 0.27
Peak DBP (mmHg) 1.30±14.31 1.42±13.02 1.22±15.12 0.34
Test Duration (min) 3.52±4.41 3.53±4.28 3.51±4.53 0.27
METs 2.73±2.64 2.98±2.89 2.53±2.39 0.98
Get Negative result n, (%) 153 (15.34) 67 (15.22) 86 (15.43) 0.72
Psychological status
Anxiety Score -1.99±8.31 -2.24±9.11 -1.78±7.57 0.57
Depression Score -2.04±6.54 -1.71±6.63 -2.30±6.45 0.29
General
Quality of Life 		Physical functioning 10.07±22.62 10.58±22.65 9.49±22.64 0.60
Role-Health 18.74±43.96 20.23±44.55 17.03±43.32 0.22
Body pain 9.90±25.56 9.59±24.95 10.26±26.29 0.09
General health 3.96±17.88 4.00±17.02 3.91±18.85 0.56
Energy/Fatigue 5.71±19.35 7.30±18.07 3.89±20.59 0.19
Social functioning 8.13±24.29 8.67±22.25 7.52±26.45 0.40a
Role emotional 11.45±47.55 11.93±45.95 10.91±49.42 0.97
Emotional Well being 3.82±18.34 4.42±17.27 3.14±19.51 0.63
Health related
Quality of Life 		Physical 0.46±0.86 0.48±0.86 0.45±0.86 0.58
Social 0.51±0.90 0.52±0.8 0.51±0.92 0.42
Emotional 0.22±0.76 0.22±0.74 0.22±0.78 0.33a
Open in a new tab

PCI, percutaneous coronary intervention; CABG, coronary artery bypass grafting surgery; HR, heart rate; SBP, systolic blood pressure; DBP, diastolic blood pressure

*All p-values were obtained by ANCOVA, except for quit smoking obtained by Logistic regression.

a Based on logarithmic transformation due to heterogeneity of variance.

Discussion

It is generally believed that CR should be recommended to all patients with cardiovascular disease as a secondary prevention strategy24. However, the outcomes of CR have not been compared between PCI and CABG patients in a comprehensive study from an advanced CR center in the Eastern Mediterranean region. The authors’ results suggest that both PCI and CABG patients benefited similarly from CR, as the outcomes were not significantly different between the two groups in most examined variables. These data indicate that CR is a highly effective secondary prevention strategy in coronary artery disease patients, and its priority after PCI is as equal as after CABG.

Although the goal of CR is to educate patients about the harmful effects of smoking on the heart, its efficacy is not comparable to explicit smoking cessation programs in addiction treatment centers. More than half of the Portuguese CR participants quit smoking in the follow-up evaluations, and the authors have suggested that CR is a great opportunity to educate patients and emphasize the importance of smoking cessation. In this study, the distribution of smoking status changed significantly before and after CR in each group25. This conclusion is in agreement with other studies, but without significant differences between PCI and CABG26,27.

The positive effect of CR on functional capacity after PCI and CABG has been assessed in many studies, with the vast majority reporting promising effects28-32, some of which indicated a greater benefit for patients undergoing CABG29,33,34. This is likely due to the more extensive surgical procedure with greater postoperative muscle deconditioning than with the less invasive PCI procedure, in which patients can ambulate immediately following the procedure. Therefore, CABG patients have a lower functional capacity at the entry of CR, but this phenomenon is reversible and transient with the aid of CR29,33, emphasizing the importance of CR after CABG. In this study, the authors found that both groups of patients significantly improved after CR, although no significant difference was found between CABG and PCI in physical activity, left-ventricular EF, treadmill exercise test duration, and METs.

A study on PCI demonstrated that CR positively affected all aspects of the lipid profile level35 with evidence that lipid profile components significantly decreased with CR following CABG36. Although there is a lack of evidence for a link between exercise-based CR and fasting blood sugar (FBS) in patients with PCI35, it was revealed that FBS and triglycerides (TG) decreased only in the PCI group with high-density lipoprotein cholesterol (HDL-C) increasing in both groups and no change in total cholesterol (TC) and low-density LDL-C with CR. Possible explanations are the worsening of insulin sensitivity by statins35, patients’ nutrition at home, their compliance with dietary recommendations, ethnic differences, the intensity of physical activity, and its duration. Besides, except for TG which was significantly decreased in patients with PCI, CR had the same effect on the lipid profile and FBS of CABG and PCI patients.

Both resting and peak heart rate (HR) significantly changed in both groups with no significantly greater change in favor of CABG or PCI patients. Other studies found a greater change in resting HR in patients with CABG than PCI, perhaps as an indicator of greater parasympathetic tone due to the longer convalescence period after surgery37. Nevertheless, as HR-lowering drugs such as beta-blockers are prescribed to lower the heart demand after any coronary events, therefore, HR change will be under drug control rather than a CR response.

Resting systolic blood pressure (SBP) decreased significantly and equally in both groups, however, diastolic blood pressure (DBP) and peak SBP were not affected by CR. Although some studies support the authors’ findings that exercise-based CR does not influence blood pressure (BP) in patients with either PCI or CABG,37,38 it was suggested that CABG patients had significantly lower peak DBP as well as resting and peak SBP in comparison with the group without CR39 and CR participants after PCI had significantly lower SBP and DBP35. These hemodynamic contradictions can be due to different exercise protocols with various intensities, age and gender differences, sample size variations, and medications after each procedure39.

Improvement in controlling anxiety and depression, along with enhanced general quality of life (QoL) and health-related quality of life (HR-QoL), are among the established outcomes of the CR program40-42 and were observed in the present study. However, no significant difference was found between the two intervention groups. Additionally, it has been shown that patients who underwent PCI have better HR-QoL in the short-term following CR than those who underwent CABG43. Furthermore, it was suggested that, in contrast to the CABG patients, PCI patients would have better HR-QoL after the intervention and before the CR, suggesting that greater improvement may be observed in CABG than in PCI44. Although it remains controversial, these findings are linked to possible confounding factors like age, sex, socioeconomic status, education level, body weight, and comorbid disease43,45.

This study could have been limited by the fact that medical documents of one CR referral center were reviewed, and socioeconomic status, educational level, and logistic factors were not evaluated. According to the authors’ observation, although CR is advised after both PCI and CABG, more CABG patients participated due to the low PCI referral rate. Moreover, the retrospective nature of the study should be taken into account.

Conclusion

Both PCI and CABG patients from the Eastern Mediterranean region benefit significantly, and to the same extent, from CR. Therefore, it indicates that CR should be supported by the healthcare insurances, noticed by policymakers, and recommended by the physician to both groups.

Acknowledgment

We express our gratitude toward Professor of Emeritus Dr. Neil Oldridge for his kind help, Isfahan Cardiovascular Research Institute, and Cardiac Rehabilitation Research Center staff, and finally Mr. Amirsalar Moazen Safaei for his technical notes through the manuscript.

Conflict of Interest

All authors declare no potential conflict of interest.

Funding

The present research was supported by the Research Council of Isfahan University of Medical Science as a medical student thesis [number: 398216] and did not receive any grants from non-profit organizations and funding agencies in the public and commercial sectors.

Author’s Contributions

Conceptualization: Masoumeh Sadeghi, Hamidreza Roohafza; Data Curation: Erfan Sheikhbahaei, Mohammadmahdi Hadavi, Safoura Yazdekhasti; Formal Analysis: Razieh Hassannejad; Funding Acquisition: Masoumeh Sadeghi, Erfan Sheikhbahaei; Investigation: Masoumeh Sadeghi, Hamidreza Roohafza; Methodology: Masoumeh Sadeghi, Hamidreza Roohafza, Dominique Hansen; Project Administration: Masoumeh Sadeghi, Erfan Sheikhbahaei; Supervision: Masoumeh Sadeghi, Hamidreza Roohafza; Validation:Masoumeh Sadeghi, Dominique Hansen, Sina Rouhani; Writing – Original Draft Preparation: Erfan Sheikhbahaei, Sina Rouhan; Writing – Review & Editing: all of the authors.

References

  • 1.Mozaffarian D, Benjamin EJ, Go AS, Arnett DK, Blaha MJ, Cushman M, et al. Heart Disease and Stroke Statistics-2016 Update: A Report From the American Heart Association. Circulation. 2016 Jan;133(4): e38–360. doi: 10.1161/CIR.0000000000000350. [DOI] [PubMed] [Google Scholar]
  • 2.Yusuf S, Rangarajan S, Teo K, Islam S, Li W, Liu L, et al. Cardiovascular risk and events in 17 low-, middle-, and high-income countries. N Engl J Med. 2014 Aug;371(9): 818–27. doi: 10.1056/NEJMoa1311890. [DOI] [PubMed] [Google Scholar]
  • 3.Jokar F, Yousefi H, Yousefy A, Sadeghi M. Begin Again and Continue With Life: A Qualitative Study on the Experiences of Cardiac Rehabilitation Patients. J Nurs Res. 2017 Oct;25(5):344–52. doi: 10.1097/JNR.0000000000000220. [DOI] [PubMed] [Google Scholar]
  • 4.Thomas RJ, Balady G, Banka G, Beckie TM, Chiu J, Gokak S, et al. 2018 ACC/AHA Clinical Performance and Quality Measures for Cardiac Rehabilitation: A Report of the American College of Cardiology/American Heart Association Task Force on Performance Measures. J Am Coll Cardiol. 2018 Apr;71(16):1814–37. doi: 10.1016/j.jacc.2018.01.004. [DOI] [PubMed] [Google Scholar]
  • 5.Thomas RJ, Huang HH. Cardiac Rehabilitation for Secondary Prevention of Cardiovascular Disease: 2019 Update. Curr Treat Options Cardiovasc Med. 2019 Sep;21(10):56 . doi: 10.1007/s11936-019-0759-7. [DOI] [PubMed] [Google Scholar]
  • 6.Kachur S, Chongthammakun V, Lavie CJ, De Schutter A, Arena R, Milani RV, et al. Impact of cardiac rehabilitation and exercise training programs in coronary heart disease. Prog Cardiovasc Dis. 2017 Jun-Jul;60(1):103–14. doi: 10.1016/j.pcad.2017.07.002. [DOI] [PubMed] [Google Scholar]
  • 7.Grace SL, Midence L, Oh P, Brister S, Chessex C, Stewart DE, et al. Cardiac Rehabilitation Program Adherence and Functional Capacity Among Women: A Randomized Controlled Trial. Mayo Clin Proc. 2016 Feb;91(2):140–8. doi: 10.1016/j.mayocp.2015.10.021. [DOI] [PubMed] [Google Scholar]
  • 8.Kotseva K, Wood D, De Bacquer D. EUROASPIRE investigators Determinants of participation and risk factor control according to attendance in cardiac rehabilitation programmes in coronary patients in Europe: EUROASPIRE IV survey. Eur J Prev Cardiol. 2018 Aug;25(12):1242–51. doi: 10.1177/2047487318781359. [DOI] [PubMed] [Google Scholar]
  • 9.Mehra VM, Gaalema DE, Pakosh M, Grace SL. Systematic review of cardiac rehabilitation guidelines: Quality and scope. Eur J Prev Cardiol. 2020 Jun;27(9):912–28. doi: 10.1177/2047487319878958. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 10.Salzwedel A, Jensen K, Rauch B, Doherty P, Metzendorf MI, Hackbusch M, et al. Effectiveness of comprehensive cardiac rehabilitation in coronary artery disease patients treated according to contemporary evidence based medicine: Update of the Cardiac Rehabilitation Outcome Study (CROS-II) Eur J Prev Cardiol. 2020 Nov;27(16):1756–74. doi: 10.1177/2047487320905719. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 11.Turk-Adawi K, Supervia M, Lopez-Jimenez F, Pesah E, Ding R, Britto RR, et al. Cardiac Rehabilitation Availability and Density around the Globe. EClinicalMedicine. 2019 Jul;13:31–45. doi: 10.1016/j.eclinm.2019.06.007. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 12.Supervia M, Turk-Adawi K, Lopez-Jimenez F, Pesah E, Ding R, Britto RR, et al. Nature of Cardiac Rehabilitation Around the Globe. EClinicalMedicine. 2019 Jul;13:46–56. doi: 10.1016/j.eclinm.2019.06.006. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 13.Pesah E, Turk-Adawi K, Supervia M, Lopez-Jimenez F, Britto R, Ding R, et al. Cardiac rehabilitation delivery in low/middle-income countries. Heart. 2019 Dec;105(23):1806–12. doi: 10.1136/heartjnl-2018-314486. [DOI] [PubMed] [Google Scholar]
  • 14.Yang X, Li Y, Ren X, Xiong X, Wu L, Li J, et al. Effects of exercise-based cardiac rehabilitation in patients after percutaneous coronary intervention: A meta-analysis of randomized controlled trials. Sci Rep. 2017 Mar;7:44789. doi: 10.1038/srep44789. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 15.Moghaddam MHB, Aghdam FB, Jafarabadi MA, Allahverdipour H, Nikookheslat SD, Safarpour S. The Iranian version of International Physical Activity Questionnaire (IPAQ) in Iran: Content and construct validity, factor structure, internal consistency and stability. World Appl Sci J. 2012;18(8):1073–80. [Google Scholar]
  • 16.Lang RM, Badano LP, Mor-Avi V, Afilalo J, Armstrong A, Ernande L, et al. Recommendations for cardiac chamber quantification by echocardiography in adults: an update from the American Society of Echocardiography and the European Association of Cardiovascular Imaging. Eur Heart J Cardiovasc Imaging. 2015 Mar;16(3):233–70. doi: 10.1093/ehjci/jev014. [DOI] [PubMed] [Google Scholar]
  • 17.Shah BN. On the 50th anniversary of the first description of a multistage exercise treadmill test: re-visiting the birth of the ‘Bruce protocol’. Heart. 2013;99(24):1793–4. doi: 10.1136/heartjnl-2013-304003. [DOI] [PubMed] [Google Scholar]
  • 18.Bruce RA, McDonough JR. Stress testing in screening for cardiovascular disease. Bull N Y Acad Med. 1969 Dec;45(12):1288–305. [PMC free article] [PubMed] [Google Scholar]
  • 19.Khorvash F, Askari G, Vesal S, Mehrbod N, Ghasemi H, Fatehizade M, et al. Investigating the anxiety level in Iranian medical residents in 2010-2011. Int J Prev Med. 2013 May;4(Suppl 2):S318–22. [PMC free article] [PubMed] [Google Scholar]
  • 20.Ghassemzadeh H, Mojtabai R, Karamghadiri N, Ebrahimkhani N. Psychometric properties of a Persian-language version of the Beck Depression Inventory--Second edition: BDI-II-PERSIAN. Depress Anxiety. 2005;21(4):185–92. doi: 10.1002/da.20070. [DOI] [PubMed] [Google Scholar]
  • 21.Montazeri A, Goshtasebi A, Vahdaninia M, Gandek B. The Short Form Health Survey (SF-36): translation and validation study of the Iranian version. Qual Life Res. 2005 Apr;14(3):875–82. doi: 10.1007/s11136-004-1014-5. [DOI] [PubMed] [Google Scholar]
  • 22.Abbasi M, Momenyan S, Eslamimoqadam F, Sarvi F, Khaki I. Validity and reliability of the macnew heart disease health-related quality of life questionnaire in patients with heart failure: The persian version. Int Cardiovasc Res J. 2017;11(4):137–42. [Google Scholar]
  • 23.Jafari F, Hadizadeh MH, Zabihi R, Ganji K. Comparison of depression, anxiety, quality of life, vitality and mental health between premenopausal and postmenopausal women. Climacteric. 2014;17(6):660–5. doi: 10.3109/13697137.2014.905528. [DOI] [PubMed] [Google Scholar]
  • 24.Hansen D, Piepoli MF, Doehner W. The importance of rehabilitation in the secondary prevention of cardiovascular disease. Eur J Prev Cardiol. 2019 Feb;26(3):273–6. doi: 10.1177/2047487318809459. [DOI] [PubMed] [Google Scholar]
  • 25.Magalhães S, Miguel Ribeiro M, Barreira A, Fernandes P, Torres S, Lopes Gomes J, et al. Efeitos a longo prazo de um programa de reabilitação cardíaca no controlo dos fatores de risco cardiovasculares [Long-term effects of a cardiac rehabilitation program in the control of cardiovascular risk factors] Rev Port Cardiol. 2013 Mar;32(3):191–9. doi: 10.1016/j.repc.2012.08.005. [DOI] [PubMed] [Google Scholar]
  • 26.Katz DA, Buchanan DM, Weg MWV, Faseru B, Horwitz PA, Jones PG, et al. Does outpatient cardiac rehabilitation help patients with acute myocardial infarction quit smoking? Prev Med. 2019 Jan;118:51–8. doi: 10.1016/j.ypmed.2018.10.010. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 27.Sadeghi M, Shabib G, Masoumi G, Amerizadeh A, Shahabi J, Heidari R, et al. A Systematic Review and Meta-analysis on the Prevalence of Smoking Cessation in Cardiovascular Patients After Participating in Cardiac Rehabilitation. Curr Probl Cardiol. 2021 Mar;46(3):100719. doi: 10.1016/j.cpcardiol.2020.100719. [DOI] [PubMed] [Google Scholar]
  • 28.Yang X, Li Y, Ren X, Xiong X, Wu L, Li J, et al. Effects of exercise-based cardiac rehabilitation in patients after percutaneous coronary intervention: A meta-analysis of randomized controlled trials. Sci Rep. 2017 Mar;7:44789. doi: 10.1038/srep44789. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 29.Suzuki Y, Ito K, Yamamoto K, Fukui N, Yanagi H, Kitagaki K, et al. Predictors of improvements in exercise capacity during cardiac rehabilitation in the recovery phase after coronary artery bypass graft surgery versus acute myocardial infarction. Heart Vessels. 2018 Apr;33(4):358–66. doi: 10.1007/s00380-017-1076-2. [DOI] [PubMed] [Google Scholar]
  • 30.Sadeghi M, Garakyaraghi M, Taghavi M, Khosravi M, Sarrafzadegan N, Roohafza H. The Impacts of Cardiac Rehabilitation Program on Exercise Capacity, Quality of Life, and Functional Status of Coronary Artery Disease Patients with Left Ventricular Dysfunction. Rehabil Nurs. 2015 Sep-Oct;40(5):305–9. doi: 10.1002/rnj.160. [DOI] [PubMed] [Google Scholar]
  • 31.Zhang Y, Cao HX, Jiang P, Tang HQ. Cardiac rehabilitation in acute myocardial infarction patients after percutaneous coronary intervention: A community-based study. Medicine (Baltimore). 2018 Feb;97(8):e9785. doi: 10.1097/MD.0000000000009785. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 32.Da Silva Chaves GS, De Melo Ghisi GL, Grace SL, Oh P, Ribeiro AL, Britto RR. Effects of comprehensive cardiac rehabilitation on functional capacity in a middle-income country: a randomised controlled trial. Heart. 2019;105(5):406–13. doi: 10.1136/heartjnl-2018-313632. [DOI] [PubMed] [Google Scholar]
  • 33.Izawa KP, Watanabe S, Oka K, Hiraki K, Morio Y, Kasahara Y, et al. Cardiac rehabilitation outcome following percutaneous coronary intervention compared to cardiac surgery. Recent Pat Cardiovasc Drug Discov. 2011 May;6(2):133–9. doi: 10.2174/157489011795933846. [DOI] [PubMed] [Google Scholar]
  • 34.Jelinek HF, Huang ZQ, Khandoker AH, Chang D, Kiat H. Cardiac rehabilitation outcomes following a 6-week program of PCI and CABG Patients. Front Physiol. 2013 Oct;4:302. doi: 10.3389/fphys.2013.00302. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 35.Deskur-Smielecka E, Borowicz-Bienkowska S, Maleszka M, Wilk M, Nowak A, Przywarska I, et al. Early phase 2 inpatient rehabilitation after acute coronary syndrome treated with primary percutaneous coronary intervention: short- and long-term effects on blood pressure and metabolic parameters. Am J Phys Med Rehabil. 2011 Jul;90(7):589–98. doi: 10.1097/PHM.0b013e3182063bec. [DOI] [PubMed] [Google Scholar]
  • 36.Hayta E, Korkmaz Ö. Cardiac Rehabilitation Increases the Reliability of the 6-Minute Walk Test in Patients After Coronary Artery Bypass Graft Surgery. Heart Surg Forum. 2017 Dec;20(6):E247–E51. doi: 10.1532/hsf.1737. [DOI] [PubMed] [Google Scholar]
  • 37.Soleimani A, Alidoosti M, Salarifar M, Kassaian SE, Karimi A, Davoodi S, et al. Effect of cardiac rehabilitation program on heart rate recovery after percutaneous coronary intervention and coronary artery bypass grafting. J Tehran Univ Hear Cent. 2008;3(1):11–6. [Google Scholar]
  • 38.Oldridge N. Exercise-based cardiac rehabilitation in patients with coronary heart disease: Meta-analysis outcomes revisited. Future Cardiol. 2012;8:729–51. doi: 10.2217/fca.12.34. [DOI] [PubMed] [Google Scholar]
  • 39.G Ghashghaei FE, Sadeghi M, Marandi SM, Ghashghaei SE. Exercise-based cardiac rehabilitation improves hemodynamic responses after coronary artery bypass graft surgery. ARYA Atheroscler. 2012 Winter;7(4):151–6. [PMC free article] [PubMed] [Google Scholar]
  • 40.Rajati F, Feizi A, Tavakol K, Mostafavi F, Sadeghi M, Sharifirad G. Comparative Evaluation of Health-Related Quality of Life Questionnaires in Patients With Heart Failure Undergoing Cardiac Rehabilitation: A Psychometric Study. Arch Phys Med Rehabil. 2016 Nov;97(11):1953–62. doi: 10.1016/j.apmr.2016.05.010. [DOI] [PubMed] [Google Scholar]
  • 41.Pogosova N, Saner H, Pedersen SS, Cupples ME, McGee H, Höfer S, et al. Cardiac Rehabilitation Section of the European Association of Cardiovascular Prevention and Rehabilitation of the European Society of Cardiology Psychosocial aspects in cardiac rehabilitation: From theory to practice A position paper from the Cardiac Rehabilitation Section of the European Association of Cardiovascular Prevention and Rehabilitation of the European Society of Cardiology. Eur J Prev Cardiol. 2015 Oct;22(10):1290–306. doi: 10.1177/2047487314543075. [DOI] [PubMed] [Google Scholar]
  • 42.Zheng X, Zheng Y, Ma J, Zhang M, Zhang Y, Liu X, et al. Effect of exercise-based cardiac rehabilitation on anxiety and depression in patients with myocardial infarction: A systematic review and meta-analysis. Heart Lung. 2019 Jan;48(1):1–7. doi: 10.1016/j.hrtlng.2018.09.011. [DOI] [PubMed] [Google Scholar]
  • 43.Yazdani-Bakhsh R, Javanbakht M, Sadeghi M, Mashaiekhi A, Ghaderi H, Rabiei K. Comparison of health-related quality of life after percutaneous coronary intervention and coronary artery bypass surgery. ARYA Atheroscler. 2016;12(3):124–31. [PMC free article] [PubMed] [Google Scholar]
  • 44.Montesano M, Reed JL, Tulloch HE, Pipe AL, Terada T. Cardiac rehabilitation is associated with greater improvements in psychological health following coronary artery bypass graft surgery when compared with percutaneous coronary intervention. Appl Physiol Nutr Metab. 2020 Dec;45(12):1339–44. doi: 10.1139/apnm-2020-0213. [DOI] [PubMed] [Google Scholar]
  • 45.Grace SL, Bennett S, Ardern CI, Clark AM. Cardiac rehabilitation series: Canada. Prog Cardiovasc Dis. 2014 Mar-Apr;56(5):530–5. doi: 10.1016/j.pcad.2013.09.010. [DOI] [PMC free article] [PubMed] [Google Scholar]

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