Life After the Stent or the Scalpel: Comparative Study of Quality of Life after 1 year following Coronary Revascularization

Abstract

Background:

Coronary artery bypass grafting (CABG) and percutaneous coronary intervention (PCI) are established revascularization procedures for coronary artery disease. While both improve survival and relieve symptoms, their comparative impact on long-term quality of life (QoL), particularly in low- and middle-income countries like India, remains underexplored. This study aimed to assess and compare Quality of life in patients one year after CABG and PCI.

Methodology:

This cross-sectional comparative study included 100 patients aged 40–65 years, comprising 50 individuals who underwent coronary artery bypass grafting (CABG) and 50 who underwent percutaneous coronary intervention (PCI), evaluated one year after their respective revascularization procedures. Data were collected using a semi-structured proforma, and quality of life was assessed with the Hindi version of the World Health Organization Quality of Life - BREF (WHOQOL-BREF) scale.

Results:

Baseline sociodemographic and clinical characteristics were comparable between groups. CABG patients had significantly higher total QoL scores compared to PCI patients (66.59±6.69 vs. 63.34±9.39, p=0.050). Physical health (p=0.012) and environmental (p=0.030) domains were significantly better in the CABG group. Psychological and social domains showed no significant difference. Comorbidities including Diabetes and Hypertension negatively affected QoL in both groups, while education was positively associated with QoL in CABG patients.

Conclusion:

The study revealed that CABG is associated with better physical, environmental, and overall QoL one year after revascularization compared to PCI. Addressing comorbidities and sociodemographic factors is essential to improve long-term QoL in these patients.

Introduction

Cardiovascular diseases (CVDs) remain the leading cause of death worldwide, with an estimated 19.8 million fatalities in 2022, accounting for about 32% of all global deaths, and coronary artery disease (CAD) representing the largest share. Among these, 85% were due to heart attacks and strokes, with over three-quarters of CVD deaths occurring in low- and middle-income countries (LMIC).¹ India alone contributes to one-fifth of global CVD mortality, particularly affecting younger adults, with a pooled prevalence of 11%–13% among adults, and CVDs are responsible for roughly 25% of all deaths nationally.² Beyond physical illness, cardiac conditions profoundly affect mental health, resulting in substantial deterioration in patients’ overall quality of life.³

Percutaneous Coronary Intervention (PCI) and Coronary Artery Bypass Grafting (CABG) are primary revascularization procedures for CAD. PCI is a minimally invasive procedure using stents and allows quicker recovery, often preferred for single/double-vessel disease. On the other hand, CABG is an open-heart surgery that is more invasive and often offers better long-term outcomes, particularly for complex, multi-vessel disease.⁴ Both procedures help reduce symptoms and enhance survival, yet their long-term impact on quality of life, especially in low- and middle-income countries, remains underexplored, despite the high disease burden.

In recent years, Social and functional quality of life (QoL) has emerged as a major patient-centred outcome in the evaluation of treatment effectiveness apart from survival rate. Improvements in survival following revascularization have shifted the focus from mere longevity to the quality of survival.⁵

Follow-up studies comparing quality of life (QoL) after Coronary Artery Bypass Grafting (CABG) and Percutaneous Coronary Intervention (PCI) show variable results. Large trials like Coronary Angioplasty versus Bypass Revascularization Investigation (CABRI), Randomized Intervention Treatment of Angina (RITA) and Fractional Flow Reserve versus Angiography for Multivessel Evaluation 3 (FAME 3) found comparable 1-year QoL for both procedures in single-vessel or less complex disease, with PCI allowing faster early recovery.^6-8 In contrast, another trials like Synergy Between Percutaneous Coronary Intervention With Taxus and Cardiac Surgery (SYNTAX) trial, Future Revascularization Evaluation in Patients With Diabetes Mellitus: Optimal Management of Multivessel Disease (FREEDOM) trial and other studies reported superior 1-year QoL, angina relief, and physical functioning with CABG, particularly in multivessel or complex cases, suggesting more durable benefits.^9-14 CABG offered slightly better physical functioning, but without statistically significant differences in some cohorts.¹⁵ Indian data on this area is very scarce. Limited Indian studies noted substantial QoL gains after CABG within a year in comparison to PCI^16,17, while others reported improvement in Quality of Life with both CABG and PCI at six months, with PCI showing a slight advantage after adjustment for clinical factors.¹⁸

Assessment of QoL one year after revascularization is particularly relevant, as this period allows adequate recovery from surgery, stabilization after intervention, and adaptation to lifestyle modifications. It also reflects sustained benefits rather than short-term postoperative effects. Additionally, sociocultural factors, healthcare access, and availability of rehabilitation services in India can significantly affect recovery and patients perceived quality of life.

Evaluating patients one year after the procedure provides a more complete picture of quality of life by minimizing the effects of immediate post-procedural complications and short-term psychological stress. There is limited Indian literature from Low Middle-Income Countries (LMIC) like India evaluating the quality of life one year after coronary revascularization. Therefore, this study was designed to assess and compare the quality of life in patients one year after undergoing Coronary Artery Bypass Grafting (CABG) and Percutaneous Coronary Intervention (PCI).

Material and Methods

This cross-sectional comparative study was conducted in a tertiary care hospital between 1 July 2021 to 30 September 2021. A total of 100 patients were included. Among them, 50 patients had undergone percutaneous coronary intervention (PCI), and 50 had undergone coronary artery bypass grafting (CABG) one year before the study. These patients were attending their respective outpatient departments of hospitals affiliated with the medical college. Participants were enrolled after applying the predefined inclusion and exclusion criteria.

Patients were included if they had undergone PCI or CABG at least one year prior to the study, were between 40 and 65 years of age, and were married and living with their families. Patients were excluded if they were unmarried, separated, or living alone; had serious medical or surgical illness; had a previous psychiatric illness; were uncooperative or unwilling to give consent; or were taking drugs or substances that could affect their emotional state.

A formal sample size calculation was not performed as only eligible participants meeting the inclusion criteria were recruited using a non-probability purposive sampling method during the limited study period due to time constraints.

Tools

The following tools were used in the study-

• 1.A semi-structured proforma to record various sociodemographic and clinical variables.
• 2.World Health Organization Quality of Life Assessment scale WHOQOL – BREF, (Hindi version)¹⁹- It has 26 items, each rated on a five-point likert scale. These items are distributed in 4 domains, including physical health, psychological health, social relationships and environmental health. Domain scores are scaled in a positive direction, with higher scores denoting a better quality of life. The mean score of items within each domain is used to calculate the domain scores compatible with the scores used in WHOQOL-100 and subsequently transformed to a 0-100 scale using the following formula:

$\text{Transformed score}=\frac{\text{(Actual raw domain score - lowest possible raw domain score)}}{\text{Possible raw domain score range}}\times 100$

Alternatively, a standard table can be used for the conversion of raw scores to transformed scores.

Ethical consideration

The study was approved by the Institutional Ethics Committee of our institute (Approval No: Acad/EC/2021/44 dated 15/03/2021). Participants were assured that all information provided would be kept confidential and used solely for research purposes, and written informed consent was obtained thereafter. All the patients were informed about the purpose of the study and were told that they could withdraw from the interview at any time without any consequences.

Statistical analysis

The collected data were analysed using SPSS software version 23.0. Categorical variables were presented as frequencies and percentages, while continuous variables were expressed as means and standard deviation. Data normality was assessed using the Shapiro–Wilk test.

The Chi-square test was used to compare categorical sociodemographic and clinical variables between the PCI and CABG groups. The independent samples Student’s t-test was applied to compare mean scores, including quality of life scores, between the two groups. Pearson’s correlation coefficient was used to assess the relationship between quality-of-life domains and selected sociodemographic and clinical variables, except gender and occupation. Since the quality-of-life data for gender and occupation were not normally distributed, their association was analysed using non-parametric tests, specifically the Mann–Whitney U test for gender and the Kruskal–Wallis test for occupation.

Results

Table 1.

Sociodemographic and clinical profile of patients in the CABG and PCI group

Variable	Subgroup	CABG	PCI	Chi square value	p value
		N (%)	N (%)
	40 – 45 years	9(18)	9(18)
	46 – 50 years	6(12)	8(16)
Age	51 – 55 years	7(14)	7(14)	0.391	0.94
	56 – 60 years	8(16)	8(16)
	61 – 65 years	20(40)	18(36)
Gender	Male	45(90)	41(82)	1.322	0.25
	Female	5(10)	9(18)
	Illiterate	15(30)	20(40)
	Primary	5(10)	9(18)
Education	Middle	11(22)	10(20)	7.105	0.13
	Secondary	15(30)	8(16)
	Sr. Secondary	4 (8)	3(6)
	Unemployed	2(4)	8(16)
Occupation	Labourer	18(36)	15(30)
	Farmer	14(28)	8(16)
	Govt. Job	2(4)	1(2)	4.178	0.52
	Homemaker	4(8)	8(16)
	Others	10(20)	10(20)
	<5000	22(44)	14(28)
Monthly Income in	5000 – 10000	10(20)	18(36)	4.063	0.13
rupees	>10000	18(36)	18(36)
	No	8(16)	16(32)
	Hypertension (HTN)	22(44)	23(46)	5.578	0.14
Comorbidities	Diabetes Mellitus (DM)	10(20)	4(8)
	Both HTN & DM	10(20)	7(14)
	1-3 years	27(54)	31(62)	0.657
Duration since	>3 years	23(46)	19(38)		0.42
procedure

Participants in both CABG and PCI groups were aged between 40–65 years, with the majority in the 61–65-year age group. Males constituted the majority in both groups (90% CABG; 82% PCI). No statistically significant differences were observed between CABG and PCI groups with respect to all sociodemographic and clinical variables.

The CABG and PCI groups were comparable in baseline characteristics, with no statistically significant differences observed across variables. Mean age, education, monthly income, number of comorbidities, and duration since procedure were similar between the two groups (p > 0.05). (Table 2)

Table 2.

Sociodemographic and clinical profile of patients in CABG and PCI group (Continuous variables)

Variable	CABG	PCI	t value	p value
	Mean ±SD	Mean ±SD
Age in years	55.5 ± 7.96	55.1 ± 7.72	0.25	0.80
Education in years	2.76 ± 1.37	2.30 ±1.30	1.72	0.08
Monthly Income in rupees	9540±6122.758	10320±6452.464	-0.62	0.54
Number (No.) of Comorbidities	1.04 ± 0.60	0.82±0.65	1.76	0.08
Duration since procedure in years	3.70 ±3.810	3.98±3.007	0.41	0.68

Patients in the CABG group showed statistically significantly higher total quality of life score (66.59 ± 6.69 vs. 63.34 ± 9.39, p = 0.050). Physical health scores were significantly better in the CABG group (62.78 ± 9.90 vs. 56.82 ± 13.09, p = 0.012), as were environmental scores (67.16 ± 7.34 vs. 63.62 ± 9.46, p = 0.030). Differences in psychological health and social relationships were not statistically significant, indicating that both procedures provided comparable benefits in these areas. Overall, CABG was associated with modestly better long-term QoL, particularly in physical and environmental domains. (Table 3).

Table 3.

Comparison of QoL scores between CABG and PCI patients

Quality of life domains	CABG group Mean + SD	PCI group Mean + SD	t value	p value
Physical Health	62.78±9.90	56.82±13.09	2.567	0.012*
Psychological Health	68.84±8.73	66.52±11.74	1.120	0.285
Social Relationship	67.58±7.01	66.42±9.48	0.695	0.488
Environment	67.16±7.34	63.62±9.46	2.089	0.030*
Total QOL	66.59±6.69	63.34±9.39	1.989	0.050*

* Significant (p<0.05)

Table 4.

Correlation of QoL of CABG patients with socio-demographic and clinical variables.

Variables			Quality of Life Domains			Total Quality of Life Score
		Physical Health	Psychological Health	Social Relationship	Environmental
Age	r	-.097	.027	-.098	.005	-.049
	p	.504	.852	.499	.974	.436
Education in years	r	.368**	.439**	.423**	.263	.438**
	p	.009	.001	.002	.065	.001
Monthly income	r	-.025	.003	.155	.015	.035
	p	.863	.985	.283	.916	.809
No. of co- morbidities	r	-.402**	-.241	-.016	-.104	-.484**
	p	.004	.103	.924	.486	.001
Duration since procedure	r	-.078	-.022	.018	-.064	-.046
	p	.591	.881	.902	.657	.753

**Correlation is significant at the 0.01 level (2-tailed), r = Pearson correlation coefficient

Education showed a significant positive correlation with physical, psychological, social, and total quality of life domains (p < 0.01), while no significant association was found with the environmental domain. The number of co-morbidities demonstrated a significant negative correlation with physical health and total quality of life (p < 0.01), indicating poorer outcomes with increasing co-morbidities.

No statistically significant differences were found in quality-of-life domains across gender and occupational groups in the CABG group, based on the Mann–Whitney U test and Kruskal–Wallis test, respectively. (Table 5 and 6)

Table 5.

Association of QoL of CABG patients with Gender by using the Mann–Whitney U test

Variable	Gender (Mean rank)		U	p value
	Male	Female
Physical Health	26.50	20.94	143.500	.306
Psychological Health	26.73	19.89	134.000	.211
Social Relationship	25.50	25.50	184.500	.1.000
Environmental	25.29	26.44	193.000	.843
Total Quality of Life Score	26.70	20.06	135.500	.220

Table 6.

Association of QoL of CABG patients with Occupation by using the Kruskal–Wallis test

Variable	Kruskal-Wallis Test For Occupation	p value
Physical Health	2.936	.710
Psychological Health	6.518	.259
Social Relationship	6.466	.264
Environmental	8.909	.113
Total Quality of Life Score	4.072	.539

The number of co-morbidities showed a significant negative correlation with physical health and total quality of life, indicating poorer outcomes with increasing co-morbidities in patient underwent PCI. (Table 7)

Table 7.

Correlation of QoL of PCI patients with socio-demographic and clinical variables.

Variables			Quality of Life Domains			Total Quality of Life Score
		Physical Health	Psychological Health	Social Relationship	Environmental
Age	r	-.101	.164	-.101	.041	.001
	p	.487	.256	.486	.777	.994
Education in years	r	-.013	-.080	-.026	.064	-.020
	p	.930	.581	.859	.660	.890
Monthly income	r	.048	-.023	-.045	.082	.021
	p	.740	.877	.758	.572	.884
No of co- morbidities	r	-.353**	-.269	-.169	-.245	-.330**
	p	.012	.059	.240	.087	.019
Duration since procedure	r	-.113	.088**	.086	.097	.036
	p	.436	.011	.544	.502	.804

**Correlation is significant at the 0.01 level (2-tailed), r = Pearson correlation coefficient

No statistically significant differences were found in quality-of-life domains across gender and occupational groups in the CABG group, based on the Mann–Whitney U test and Kruskal–Wallis test, respectively. (Table 8 and 9)

Table 81.

Association of QoL of PCI patients with Gender by using the Mann–Whitney U test

Variable	GENDER (Mean rank)		U	p value
	Male	Female
Physical Health	25.66	24.10	105.500	.818
Psychological Health	25.92	21.70	93.50	.550
Social Relationship	26.24	18.80	79.00	.296
Environmental	26.00	21.00	90.00	.488
Total Quality of Life Score	26.02	20.80	89.00	.469

Table 9.

Association of QoL of PCI patients with Occupation by using the Kruskal–Wallis test

Variable	Kruskal-Wallis Test For Occupation	p value
Physical Health	2.141	.544
Psychological Health	4.746	.191
Social Relationship	3.942	.268
Environmental	3.198	.362
Total Quality of Life Score	4.337	.227

Discussion

This study evaluated the quality of life one year after Coronary Artery Bypass Grafting (CABG) and Percutaneous Coronary Intervention (PCI). Results showed that CABG patients had significantly higher scores in physical health and environmental domains, as well as overall quality of life, while psychological and social relationship domains were similar between the groups. These findings suggest that although both procedures improve overall well-being, CABG may provide more lasting benefits in physical functioning and environmental satisfaction. Better physical outcomes in CABG patients are likely due to complete and more durable revascularization and enhanced ability to perform daily activities.

Several studies^11,12,20-23 have reported similar findings, showing that CABG is associated with better longterm physical health and overall quality of life compared to PCI, as assessed by both disease-specific and generic QoL measures. This has been further supported by major randomized trials such as the Bypass Angioplasty Revascularization Investigation (BARI),²⁴ SYNTAX, ^9, and FREEDOM¹⁰ trial, which found that while both procedures improve quality of life at one year, CABG provides more lasting and significant benefits, especially in patients with more complex or multivessel coronary artery disease.

Several systematic reviews and meta-analyses have demonstrated the advantages of CABG over PCI in terms of quality of life. One large review reported that CABG led to superior QoL scores across all measured domains at 6 months and 1-year post-procedure.²⁵ CABG provides better long-term angina relief, reduces repeat revascularizations over 1–5 years, and improves both physical and mental components of quality of life.^26-27A recent meta-analysis of 32 randomized controlled trials further confirmed that CABG is associated with lower rates of repeat procedures and myocardial infarction, offering more durable revascularization and better long-term functional outcomes.²⁸

On the other hand, trials like CABRI, RITA, and FAME 3 reported similar quality of life at one year for both CABG and PCI, showing no statistically significant difference.^6-8 Some studies with shorter follow-up, such as at three months, also found no significant difference in quality of life between the two procedures.¹⁵Evidence from India, though limited, indicates that CABG patients had significantly better improvements in physical, emotional, and social QoL and overall QoL at one year,^16,17 whereas other studies at six months reported improved QoL with both procedures, PCI showed slightly higher but non-significant overall QoL after adjusting for clinical factors.¹⁸

Differences in quality-of-life outcomes between CABG and PCI across studies may be due to variations in disease severity, patient characteristics, follow-up duration, and assessment methods. PCI often shows similar or better short-term QoL due to faster recovery, while CABG tends to provide more sustained benefits in patients with complex or multivessel disease. The environmental domain of quality of life, encompassing financial resources, physical safety, access to healthcare, recreation, and transportation, was also significantly better in CABG patients. This may reflect greater long-term symptom stability, lower hospital visits and reduced need for repeat interventions after CABG, giving patients greater autonomy and participation in recreational and social activities.²⁵ Improved environmental satisfaction after CABG has been less commonly emphasized in the literature, making this a significant finding of the present study.

In contrast, psychological and social relationship domains didn’t differ significantly between CABG and PCI patients. Psychological outcomes following revascularization are influenced by multiple factors, including illness perception, fear of recurrence, and coping mechanisms.²⁹ Research has shown that anxiety and depressive symptoms may persist even after successful revascularization, irrespective of the procedure type.³⁰The lack of significant difference in psychological domains between CABG and PCI in the present study may therefore reflect a common trajectory of psychological adaptation rather than procedure-specific effects.

Comorbid medical conditions were found to be important determinants of quality of life in both CABG and PCI patients. In both groups, physical health and overall QoL were negatively affected by comorbidities such as hypertension and diabetes. Chronic illnesses contribute to ongoing symptoms, medication use, dietary restrictions, and lifestyle modifications, which can reduce perceived well-being even after successful revascularization. These results align with previous studies reporting poorer quality of life in patients with diabetes and hypertension following coronary interventions.^31-34

Sociodemographic factors also played a role in quality-of-life outcomes, particularly among CABG patients. Higher educational levels were associated with better physical, psychological, and social domains and overall quality of life. Education likely enhances health literacy, helping patients understand their condition, follow medical guidance, and adopt healthier lifestyles.^35-37

Despite the less invasive nature of PCI, which facilitates faster recovery³⁶, it may adversely affect psychological health over the long term, as reflected in our findings showing a decline in psychological well-being with increasing time since the procedure. This may reflect patients’ ongoing concerns about long-term outcomes, such as the risk of restenosis or the need for repeat interventions after PCI.^29-30These uncertainties can gradually affect psychological well-being, emphasizing the need for continued counselling and long-term follow-up after PCI.

In LMIC like India, quality-of-life outcomes after coronary revascularization are influenced by a combination of procedural, medical, and psychosocial factors, including financial constraints, limited access to structured cardiac rehabilitation, and variability in follow-up care. Patients undergoing CABG may benefit from a greater sense of definitive treatment, which can enhance perceived recovery and satisfaction, whereas PCI patients may continue to worry about disease recurrence. Overall, these findings highlight the importance of a holistic, multidisciplinary approach to post-revascularization care that combines medical management with psychosocial support to optimize long-term quality of life.

Strengths and Limitations

This study is one of the few conducted in India that compares the quality of life outcome one year after two cardiac interventional procedures, namely CABG and PCI. The study addresses a clear and clinically relevant research question and utilizes a validated quality of life instrument (WHOQOL-BREF). It also appropriately contextualizes the findings within a low- and middle-income country setting like India.

However, our study has the following limitations –

• 1.Small sample size, single-center setting, and cross-sectional design limit the generalizability of the findings.
• 2.The absence of baseline (pre-procedure) QoL data limits the ability to assess improvement and control for pre-existing differences between the CABG and PCI groups.
• 3.There is a strong possibility of selection bias, as patients undergoing CABG and PCI may inherently differ in terms of disease severity, coronary anatomy, and comorbid conditions.
• 4.Additionally, factors such as lifestyle habits, participation in cardiac rehabilitation, severity of coronary artery disease, and medication adherence were not assessed, which may affect quality of life outcomes.

Conclusion

One year after the procedure, patients who underwent CABG showed better physical, environmental, and overall quality of life compared to PCI patients, while psychological and social domains were similar. Quality of life was influenced by comorbidities such as hypertension and diabetes, as well as sociodemographic factors like education. These findings emphasize that optimizing post-revascularization outcomes requires addressing medical, psychosocial, and socioeconomic factors in addition to procedural success.

Future research should include larger, multicenter populations with longitudinal follow-up, incorporating both pre- and postoperative assessments. Studies should also consider clinical, biochemical, and lifestyle factors to achieve a more comprehensive understanding of quality-of-life outcomes following CABG and PCI.