Lifestyle practices, health problems, and quality of life after coronary artery bypass grafting

Abstract

Introduction

Severe coronary artery disease continues to be a major health problem in India, and coronary artery bypass grafting (CABG) is the accepted modality of treatment. Post-operative long-term quality of life depends on the healthy lifestyle practices and appropriate control of risk factors. We tried to bring out the patient awareness and their practices after the surgery and their implications on their quality of life (QOL).

Materials and methods

Five hundred patients who completed 6 months after isolated CABG were interrogated for their lifestyle practices, health problems, and quality of life using a structured questionnaire. Those who underwent additional cardiac procedures, redo CABG, and coronary interventions after CABG were excluded.

Results

Eighty percent were in good functional class (NYHA I, II). Detailed evaluation showed that only 11.6% adhered to healthy lifestyle practices. Obesity, uncontrolled diabetes mellitus, uncontrolled hypertension, and hypercholesterolemia continued to be problems in 9.6, 20.2, 35, and 48.4%, respectively. Quality of life was assessed to be good in 27.6%, average in 46.4%, and poor in 26%. Psychological evaluation showed that 23% were significantly anxious and 20% had significant depression. Pre-operative diagnosis and left ventricular function at discharge influenced the QOL. Unhealthy lifestyle practices and failure to attain risk factor reduction adversely affected the quality of life.

Conclusion

This study emphasises the need for aggressive counselling as well as continuing health education to improve patient awareness about adopting healthy lifestyle practices after CABG to improve the quality of life.

Electronic supplementary material

The online version of this article (10.1007/s12055-018-0671-x) contains supplementary material, which is available to authorized users.

Introduction

Indian health sector is overburdened with cardiovascular diseases (CVD), and this turns out to be one of the major causes of morbidity and mortality in this country [1]. The problem increases in severity due to the fact that this disease affects younger population almost a decade earlier than the westerners [2]. CVD still being a disease of aged among westerners constitute only 23% of death under 70 years of age. The proportion of death is higher with 52% of death being due to CVD under 70 years in Indian subcontinent [3, 4]. This accounts for a massive loss of productive working years for India. A loss of 9.2 million productive working years was estimated in India in 2000 with an expectation to rise up to 17.9 million years by 2030 (loss of productive years was calculated to be ten times when compared to the United States) [5]. The incidence of CVD has been increasing in both rural and urban populations, but it is more pronounced in urbans because of rapid changes in lifestyle and increasing incidence of risk factors. This imparts great stress on the economy of India, and we need to intervene aggressively to arrest the progression of CVD in our country to avoid alarming figures in future.

Considering the situation in a state like Kerala, there is very high prevalence of risk factors as hypertension and diabetes which when added to unhealthy lifestyle and job-related stress cause an exponential rise in the CVD incidence. CVD which constitutes about 50% of total death at present is expected to reach 66% by 2020 [6]. Higher level of literacy and urbanisation have contributed towards higher life expectancy, lower infant mortality rate, and lower maternal mortality rate but has led to a tremendous increase in the number of CVD patients reaching a rural prevalence of 7.5% and urban prevalence of 12% which is the highest in the country [6].

The experience from our institution shows a higher prevalence of diabetes and hypertension among CVD patients and an alarming rise in the number of younger patients presenting with severe CVD. Our unit is one of the largest volume cardiac centres in the state performing more than 1000 open heart operations annually, out of which 60% are coronary revascularisation procedures. Being a cardiac unit under state government sector with various schemes for financial assistance, majority of our patients belong to medium and low socioeconomic status. Coronary revascularisation procedures are performed in the bread-winning member of the family which imparts a tremendous financial and psychological burden on the family. The scenario becomes even worse with younger patients entering the coronary artery bypass grafting (CABG) list. It is a real concern and a great challenge from our part to ensure a good quality of life (QOL) for them after the procedure so that they can get back to their occupation as early as possible to support their family. This forms the justification for our study.

A pilot study conducted by MSC nursing students in our department including 100 patients 3 months after CABG exposed the lack of awareness among our patients regarding long-term management after coronary revascularisation. Though the literacy rate is high, majority of the patients in the medium and poor socioeconomic status are unaware of the need for continuing risk factor modification after coronary artery bypass surgery. Like any other surgical procedure, many patients consider CABG as a curative operation. This persuaded us to strengthen our efforts to educate the patients and their relatives about their own disease, teach them what to expect, and understand the importance of adherence to healthy lifestyle practices. Through this study, we aim to bring out the lifestyle practices adopted by our patients after CABG and the effect of their lifestyle practices and risk factor modification on the quality of life after the procedure.

Materials and methods

Ethical approval for conducting the study was obtained from hospital Research Ethics Committee. Five hundred patients who underwent isolated CABG and completed 6 months after the procedure were identified in an out-patient basis to include in the study after evaluating inclusion and exclusion criteria. All male and female patients between 30 and 70 years who underwent isolated CABG have completed 6 months after the procedure and having the ability to comprehend and communicate local language (Malayalam) were included in the study. Those who required any additional cardiac procedure (as valve interventions/closure of septal defects), redo-CABG, and any form of coronary intervention after CABG were excluded. Patients who satisfied the inclusion criteria and were willing to participate in the study were enrolled. Objectives of the study were to:

1. Identify the lifestyle practices of patients after CABG.

2. Assess the health problems of patients after CABG.

3. Determine the quality of life of patients after CABG

4. Evaluate the relationship between lifestyle practices and quality of life.

5. Derive the relationship between quality of life and selected variables

Definitions used for the study

Lifestyle practices

In this study, lifestyle practices refer to the modifications adopted by patients in their daily life after CABG.

Quality of life

In this study, quality of life is the patient’s perceived level of health status in all spheres of life-physical, social, psychological, and economic wellbeing after CABG

• Body mass index (BMI)—under weight (< 18.5), normal (18.5–24.9), over weight (25–29.9), obese (> 30)

• Diabetes mellitus (DM)

• Poor diabetic management—present FBS > 100 mg/dl and RBS > 140 mg/dl and blood sugar not checked at regular intervals (once in a month)

• Good diabetic management—2 consecutive results with FBS ≤ 100 mg/dL, RBS ≤ 140 mg/dL (1- to 2-month interval)

• Hypertension (HTN)

• Poor hypertensive management—present blood pressure (BP) ≥ 140/90 mmHg and not checked BP at regular intervals (once in a month)

• Good hypertensive management—2 consecutive results with BP < 140/90 mmHg (1-month interval)

• Cholesterol—based on total serum cholesterol levels: normal (< 200 mg/dL), borderline (200–239 mg/dL), high risk(> 240 mg/dL)

A detailed informed consent form was prepared in regional language (Malayalam) explaining the nature and objectives of the study. All subjects signed this consent and were allowed to raise questions about the study. A detailed and structured questionnaire was framed, and the patients were interviewed by a trained research assistant.

Data collection instruments

1. Section A: sociodemographic proforma

   Section B: clinical proforma

2. Section A: physical problems assessment checklist

   Section B: the hospital anxiety and depression scale

3. Questionnaire on lifestyle practices.

4. Rating scale on QOL of CABG patients.

Tool 1

It consists of two sections, section A—sociodemographic proforma—and section B—clinical proforma. Sociodemographic proforma consists of age, sex, education, present occupation, income, and personal habits after surgery. Clinical proforma includes treatment history and clinical outcome data sheet. The treatment history includes clinical diagnosis, duration after surgery, comorbidities, and left ventricular systolic function at the time of discharge. Clinical outcome data sheet highlights the New York Heart Association (NYHA) class, heart rate (HR), BP, BMI, and lipid profile.

Tool 2

It contains two sections: A and B. Section A is a checklist for physical problems and consists of problems which are commonly seen in patients after CABG.

Section B is hospital anxiety and depression scale (HADS) for assessing psychological problems of the patients after CABG. It is a standardised tool having high internal consistency and reliability. The HAD scale scores both depression and anxiety. It is a questionnaire which contains 14 questions. The rating is based upon a 4-point scale.

Among the 14 questions, seven are for depression (the questions 2, 5, 7, 9, 10, 12, 14) and the other seven for anxiety (the questions 1, 3, 4, 6, 8, 11, 13). The implications of the result are obtained through analysing the scores. The scores were classified into three categories. No depression or anxiety state, but may be at risk as determined by assessment (0–7), possible or borderline depression/anxiety (8–10), and probable significant depression or anxiety (11–21).

Tool 3

It is a structured tool, which contains 28 questions organised under five headings, such as drug compliance, dietary practice, exercise/activities, stress reduction strategies, and follow-up care. Each healthy practice scores two marks, correct problem tackling gets one mark, and unhealthy practice scores zero. The questionnaire has been included as (Appendix 1). The total score for each patient is calculated, and the mean value was obtained. Patients were categorised into three groups: group1—very poor compliance to healthy lifestyle practices (values below mean ± SD); group 2—satisfactory compliance (values within mean ± SD); group 3—excellent compliance (values above mean ± SD).

Tool 4

This tool was developed with reference to SF 36 questionnaire, an existing standard questionnaire to determine the quality of life. Rating scale was prepared under different domains such as physical, psychological, socioeconomic, and spiritual. Since our patient population belonged to medium and low socioeconomic strata, financial concerns significantly affect the QOL; hence, we included questions in socioeconomic domain also. Rest of the questions do not vary much from the SF 36 model. This is a 5-point scale. Quality of life was determined according to the score obtained by the patients and categorised into three groups based on mean and SD—good, average, and poor quality of life.

Statistical analysis

Frequency distribution and percentage were used to analyse sociodemographic data, clinical data, health problems, quality of life, and lifestyle practices of patients after CABG. Chi-square was used to identify the association between lifestyle practices and quality of life as well as the quality of life and selected variables. Differences and correlations with p < 0.05 were considered statistically significant. We used SPSS 20 software (SPSS Inc., Chicago, Illinois, USA) in the analysis.

Results

The mean age of patients was 59.2 ± 7.33 years. There were 399 males (79.8%). Eighty-four percent of patients had school level education only, and two thirds belonged to low- and medium-income group. Majority of patients were in good cardiac status at discharge with left ventricular ejection fraction being normal (> 55%) in 50.8% and with mild dysfunction (45–55%) in 38.2%. Only 11% of patients were having significant impairment of left ventricular function (< 45%). Follow-up duration ranged from 6 months to 8 years. The NYHA functional class was I or II in 80% of them, with 3.6% having class IV symptoms during follow-up. Pre-operative variables are depicted in (Table 1).

Table 1.

Pre-operative variables

Variable	No. of patients	Percentage
Gender
Male	399	20.2
Female	101	79.8
Age
30–40	6	1.2
41–50	61	12.2
51–60	159	31.8
61–70	258	51.6
> 70	16	3.2
Education
No formal education	12	2.4
School education	420	84
Higher secondary	45	9
Degree/diploma	23	4.6
Family monthly income
< 3000	70	14
3001–5000	127	25.4
5001–10,000	118	23.6
> 10,000	185	37
Comorbidity
Diabetes mellitus	228	45.6
Hypertension	276	55.2
Renal failure	11	2.2
Respiratory diseases	139	27.8
Neurological diseases	19	3.8
LV function
> 45	55	11
45–55	190	38
> 55	253	50.6
Follow-up duration after CABG
6–12 month	123	24.6
1–2 year	123	24.6
2–3 year	179	35.8
> 3 year	75	15
Pre-op diagnosis
Single vessel disease	11	2.2
Double vessel disease	59	11.8
Triple vessel disease	316	63.2
Double vessel + LMCA	33	6.6
Triple vessel + LMCA	81	16.2

During follow-up, only 61.6% of patients were maintaining ideal body weight. The prevalence of underweight, overweight, and obesity were 7, 21.8, and 9.6%, respectively. Analysing the risk factor modification among the patients, the major flaw was in maintaining a good cholesterol level with 48.4% of them having hypercholesterolemia. Diabetes and hypertension was uncontrolled in 20.2 and 35%, respectively. Twenty-three percent patients were anxious about their illness, follow-up care, and recurrence of symptoms, whereas 20% suffered from severe depression due to the illness.

Physical problems were a major concern for the patients affecting their quality of life. Angina and dyspnoea at rest were the serious problems reported but dyspnoea on exertion was the main complaint recorded by them (45.4%). Dyspnoea was evaluated and found to be due to sedentary habits and of pulmonary origin mostly. Cough was disturbing 37%, while shoulder pain and pedal oedema each were bothersome to 30% of them. Visual and hearing ailments were minor, and neurological impairment mainly included subtle memory loss (short and long term), writing disabilities, and tremors. Major neurological event as stroke was an uncommon occurrence. Post-operative variables are listed in (Table 2).

Table 2.

Post-operative variables

Variable	No. of patients	Percentage
Risk factors after CABG
Smoking	16	3.2
Alcoholism	58	11.6
Poor diabetic control	101	20.2
Poor hypertensive control	175	35
Hypercholesterolemia	242	48.4
NYHA
Class I	182	36.4
Class II	218	43.6
Class III	82	16.4
Class IV	18	3.6
BMI
Under weight	35	7
Normal	308	61.6
Over weight	109	21.8
Obese	48	9.6
Physical problems after CABG
Angina	60	12
Dyspnea at rest	32	6.4
Dyspnea on exertion	272	45.6
Palpitation	125	25
Cough	185	37
Shoulder complaints	152	30.4
Pedal edema	154	30.8
Incisional hernia	27	5.4
Vision problem	44	8.8
Hearing problem	25	5
Memory problem	85	17
Anxiety
No anxiety	202	40.4
Possible anxiety	183	36.6
Probable significant anxiety	115	23
Depression
No depression	182	36.4
Possible depression	217	43.4
Probable significant depression	101	20.2
Healthy life style practices
Poor compliance	90	18
Satisfactory compliance	352	70.4
Good compliance	58	11.6
QOL
Good	138	27.6
Average	232	46.4
Poor	130	26

Adherence to healthy lifestyle practices was excellent only in 11.6%, but majority of the patients managed to maintain a satisfactory compliance (70.4%). Eighteen percent were unconcerned and continued to adopt unhealthy lifestyle measures. Non-compliance to control of risk factors and sound lifestyle habits were reflected on the quality of life enjoyed by these patients. 27.6% had a very good QOL, whereas 26% experienced poor QOL.

Association between quality of life and selected variables are depicted in (Table 3). Pre-operative diagnosis of triple vessel disease and left main stem involvement and LV dysfunction at discharge significantly affected the quality of life. Poor control of risk factors (BMI/DM/HTN/lipid profile) had a very strong association to poor quality of life.

Table 3.

Results of chi-square test showing the association between selected variables and poor quality of life

Variables	p value
Advanced age	0.121
Male Gender	0.107
Follow-up duration	0.804
Pre-op diagnosis of left main stem and triple vessel disease	0.000**
LVEF < 45% at discharge	0.000**
Poor post-op hypertensive management	0.003**
High BMI	0.000**
High post op cholesterol	0.001**
Poor post op diabetic control	0.007**
Post op exertional dyspnea	0.000**
Post op chest pain	0.095
Post op shoulder pain	0.021*
Insomnia	0.000**
Visual impairment	0.594
Hearing deficit	0.331
Memory loss	0.38*
Anxiety	0.000**
Depression	0.000**
Unhealthy lifestyle practices	0.009**

**p < 0.001, *p < 0.05

Among the physical problems, angina, exertional dyspnoea, shoulder complaints, and insomnia notably reduced their QOL. Significant anxiety and depression greatly deteriorated the QOL. Overall, practising healthy lifestyle ensured a good quality of life with strong statistical association.

We could also associate the compliance to healthy lifestyle to the QOL (Table 4).

Table 4.

Compliance to lifestyle practices X QOL p value < 0.009

		QOL			Total
		Good QOL	Avg QOL	Poor QOL
Lifestyle	Good compliance to lifestyle practices	20 (34.5%)	29 (50%)	9 (15.5%)	58 (11.6%)
	Average compliance to lifestyle practices	95 (27%)	154 (43.75%)	103 (28.4%)	352 (70.4%)
	Poor compliance to lifestyle practices	11 (12.2%)	47 (52.2)	32 (35.5)	90 (18%)
Total		138	232	130	500

Discussion

In comparison with optimal medical management alone, coronary revascularisation with medical management provides clinically significant improvement in the quality of life of individuals with respect to symptoms and overall well-being. Hence, it is important to assess the quality of life of these patients after surgery and analyse the various parameters influencing the quality. Over the decades, due to increasing safety of cardiac surgery, the focus has shifted from improving the mortality to enhancing the quality of life.

In a study conducted to assess the quality of life 1 year after CABG by Taghipour et al. [7] in 112 patients using SF36 HRQOL questionnaire, subgroup analysis revealed PF (physical functioning) and RP (role physical) scores to be better in males. The GH (general health), PF, and RP were influenced by the left ventricular ejection fraction after CABG, diabetic status, pump type of surgery, and male gender. All patients had lower scores in other sub-categories, and they attribute this to the failure of risk factor modification and progression of comorbidities. Similar findings are obtained in our study also exposing the reproducibility of facts in different populations. Peric et al. [8] associated female gender to worse quality of life after CABG. In our study, we could not associate gender to QOL.

This conclusion is very important as the progression of comorbidities and uncontrolled risk factors negatively affect the quality of life. This has been studied by Mehta et al. [9] enrolling > 13,000 patients after CABG. While analysing 1-year clinical outcomes, they found a trend towards worse age-, gender-, and region-based outcomes with failure to attain the target values in risk factor modification. Through this study, they emphasised the need to concentrate more on the secondary prevention after CABG and aggressively tried to attain the target goals in risk factor modification in order to prevent further cardiac events thereby improving cardiac and overall health.

Physical functioning

Our patient population showed an overall good physical functioning status with majority of them in NYHA class I/II. Eighty-eight percent of patients enjoyed freedom from angina, and only 6.4% had dyspnoea at rest. This is well correlated with previous published literature with freedom from angina being the most gratifying result after CABG [10]. Shoulder complaints including pain limiting full range of movements and frozen shoulder syndrome were noted in patients who were not regular in their physiotherapy rehabilitation after the procedure. Chronic wound discharge and persistent sinus due to steel wire allergy were noticed only in a limited number of patients.

Psychosocial functioning

Researches reveal the incidence of anxiety and depression to occur between 30 and 40% in CABG patients which add to the short- and long-term morbidity after the procedure [11]. Depressive symptoms usually include a generalised depression of mood or inability to find interest or enjoy the daily life. Severe forms of depression are a minority. Similarly, generalised anxiety about recurrence of symptoms and fear of additional interventions are noted in majority of the patients after cardiac procedures. Twenty percent of our patients were having depressive symptoms, and 23% were anxious about their illness. Since the majority of people belonged to low- and medium-income group, the financial burden to the dependents to continue medications and follow-up care added to the psychological impairment in our group. This may be one of the factors causing insomnia in our patients which is found to adversely affect QOL. Psychological distress has been identified as a strong predictor for poor QOL [12].

Lifestyle practises after CABG

Objective assessment of lifestyle practises is a real practical challenge. We evaluated the lifestyle practises of our patients under five categories—drug compliance, dietary practice, exercise/activities, stress reduction strategies, and follow-up care. This gave us an overall assessment of the practises followed by our patients and enabled us to understand their concepts about exercises and a healthy dietary pattern. The overall drug compliance was good among our patients but financial concerns led to interruption of drug intake in a small group. Most of them used to skip the morning dose of medications on the day of out-patient visit due to long travel. Majority of our patients consumed mixed diet, and most of them preferred to include fish in their daily diet compared to meat. Occasional red meat consumption was common among them.

Compliance to regular exercise was seen to wean off after 3 to 6 months, as they felt a sense of well-being after surgery. Level ground walking was the routine exercise adopted by most of the patients. Routine shoulder, neck, and limb exercises were limited to the initial months after surgery. Most of the patients below 60 years returned to some form of occupational activities 6 months to 1 year after the procedure, though a general trend was noted to shift to lighter works. Older patients preferred to stay at home with household tasks. An interesting observation was that women resumed their household activities much earlier than men, but outdoor exercise activities were uncommon among ladies.

Patients tried to overcome their stress by sharing their feelings with family and friends as well as diverting their time to take care of grandchildren which is a common custom noticed in Kerala. Yoga, although evolved well in the state, was practised by very few patients for exercise as well as stress relief.

Reviewing the impact of dietary management and exercise on outcomes after CABG by Coyan et al. [13], these two interventions were undoubtedly proven to be effective and economical ways of providing secondary prevention after CABG with significant improvement in the long-term clinical outcomes.

Those patients following regular exercise programmes were found to have better physical as well as psychological well-being as reported in the literature.

As Phillip Tully [14] has rightly pointed out in his attempt to review the various QOL measurement scales, there is a real paucity of a standardised and methodically sound research tool and hence clinical studies in this field. Further rigorous efforts are demanded from the clinicians and researchers all over the world to study with precision, the quality of life, and their guiding factors.

Conclusion

This study emphasises the need for aggressive pre-operative and post-operative counselling as well as continuing health education to motivate people to maintain healthy lifestyle practices after surgical treatment for coronary artery disease in order to improve the quality of life. Awareness regarding attainment of target goals in risk factor modification should be inculcated in people to ensure good QOL. Family and social support systems should be strengthened to promote psychological well-being among patients after coronary surgeries.

Compliance with ethical standards

Conflict of interest

The authors declare that they have no conflict of interest.

Ethical statement

Ethical clearance was obtained from the institute research committee before start of the study.

Statement of animal and human rights

Procedures followed were in accordance with the ethical standards of the institutional research committee on human experimentation.

Informed consent

A detailed informed consent was prepared in regional language (Malayalam) explaining the nature of the study and was signed by all the enrolled subjects before interview.