Abstract
Aims
We conducted a systematic review and meta-analysis to evaluate temporal trends in quality of life (QoL) after coronary artery bypass grafting (CABG) surgery in randomized clinical trials, and a quantitative comparison from before surgery to up to 5 years after surgery.
Methods and results
We searched MEDLINE, CINAHL, EMBASE, Cochrane Library, and PsycINFO from 2010 to 2020 to identify studies that included the measurement of QoL in patients undergoing CABG. The primary outcome was the Seattle Angina Questionnaire (SAQ), and secondary outcomes were the 36-item Short Form Health Survey (SF-36) and EuroQol Questionnaire (EQ-5D). We pooled the means and the weighted mean differences over the follow-up period. In the meta-analysis, 2586 studies were screened and 18 full-text studies were included. There was a significant trend towards higher QoL scores from before surgery to 1 year post-operatively for the SAQ angina frequency (AF), SAQ QoL, SF-36 physical component (PC), and EQ-5D, whereas the SF-36 mental component (MC) did not improve significantly. The weighted mean differences from before surgery to 1 year after was 24 [95% confidence interval (CI): 21.6–26.4] for the SAQ AF, 31 (95% CI: 27.5–34.6) for the SAQ QoL, 9.8 (95% CI: 7.1–12.8) for the SF-36 PC, 7.1 (95% CI: 4.2–10.0) for the SF-36 MC, and 0.1 (95% CI: 0.06–0.14) for the EQ-5D. There was no evidence of publication bias or small-study effect.
Conclusion
CABG had both short- and long-term improvements in disease-specific QoL and generic QoL, with the largest improvement in angina frequency.
Keywords: Coronary artery disease, CABG, Quality of life
Introduction
Coronary artery bypass graft (CABG) surgery is the most common cardiovascular surgery performed worldwide.1,2 CABG surgery improves long-term survival and reduces major cardiac events compared with medical treatment or percutaneous coronary interventions3,4; however, it is unclear whether this clinical benefit translates into short- and long-term improvement in quality of life (QoL). Previous systematic reviews and meta-analyses have included only observational studies reporting on short-term QoL outcomes.5–7 Our objective was to evaluate temporal trends and changes in QoL, including both short- and long-term effects of CABG reported in published randomized clinical trials (RCTs) over the last 10 years. We selected RCTs because of the rigor of the study design, and the quality and completeness of follow-up data. We hypothesized that patients undergoing CABG will have improvements in both generic and disease-specific QoL.
Methods
We performed a systematic review and meta-analysis following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) statement and registered with PROSPERO (CRD42020221338).8 The data, analytic methods, and study materials will be made available to other researchers for purposes of reproducing the results.
Search strategy
A medical librarian (M.D.) performed comprehensive searches to identify studies that evaluated the impact of CABG surgery on QoL. Searches were run on 7 July 2020 in the following databases: Ovid MEDLINE (ALL 1946 to present); Ovid EMBASE (1974 to present); Cochrane Library (Wiley); PsycINFO (EBSCO); and CINAHL (EBSCO). Search terms included all subject headings and associated keywords for the concepts of coronary artery bypass surgery and QoL and then limited to RCTs using a validated filter. The full search strategy for Ovid MEDLINE is available in the Supplementary material online, Table S1.
Selection criteria
Titles and abstracts were reviewed against predefined inclusion/exclusion criteria. Inclusion criteria were the following: (i) randomized controlled trials, (ii) published after 2010, (iii) included patients undergoing CABG, and (iv) standardized QoL outcome assessment measures. Studies were excluded if they (i) were non-randomized (i.e. case series, book chapters, protocol papers), (ii) reported incomplete pre- and post-operative CABG QoL outcome assessments (e.g. no baseline values, no variance measures), (iii) reported single domains of the SF-36, or (iv) reported an EQ-5D Visual Analogue Scale measure.
After results were de-duplicated, a total of 1841 abstracts were screened by at least two reviewers (A.D., A.N., A.M., C.S.). Discrepancies were resolved by consensus or the third reviewer (R.M.C.). After abstract review, the full text of abstracts was independently assessed for eligibility by two reviewers. For articles selected for inclusion in the study, reference lists and articles citing included studies were also screened. In addition, we hand-searched recent meta-analyses and reviews on this topic for potential additional studies to be included. The full PRISMA flow diagram is shown in the Supplementary material online, Figure S1. In the case of duplication of published results from a single trial, the publication with the most thorough QoL data or longest follow-up was included.
Data extraction
Five reviewers (A.D., A.M., C.S., R.M.C., and A.N.) abstracted quantitative data from selected studies and each extraction was made blindly by two independent reviewers. Conflicts in extracted data were resolved by consensus. The extracted items included study demographics (sample size, publication year, country, study period, number of centres), baseline patient characteristics and comorbidity history (age, sex, diabetes, hypertension, chronic obstructive pulmonary disease, New York Heart Association and Canadian Cardiovascular Society class, history of previous myocardial infarction), and the QoL assessment scores at all available time points. We considered QoL values of interest at baseline, 3–6 months, 1 year, and 3–5 years after surgery (Figure 1). The QoL assessments extracted were the disease-specific Seattle Angina Questionnaire (SAQ) [angina frequency (AF), QoL, physical limitations (PLs), and treatment satisfaction (TS) domains] and generic QoL measures, including the 12- and 36-item Short Form Health Surveys [SF-12, SF-36 physical component (PC) and mental component (MC)] and EQ-5D (Table 1 and Supplementary material online, Table S2). Due to the sparsity of QoL assessments across the different trials, we focused our analysis on the ones that were more consistently reported and most relevant to CABG in the included studies (SAQ AF, SAQ QoL, SF-36 PC, SF-36 MC, and EQ-5D).
Figure 1.
Spaghetti plots showing quality-of-life scores over follow-up in all studies (left panel); whisker-plots summarizing the quality-of-life scores at each time point (right panel). EQ-5D: EuroQol Questionnaire; SAQ-AF: Seattle Angina Questionnaire—angina frequency; SF-36 PC: 36-item Short Form Health Survey (physical component); SF-36 MC: 36-item Short Form Health Survey (mental component).
Table 1.
Study characteristics
| Trial | First author (year) | CABG patients (n) | Country | Study period | Intervention/comparison groups | Outcome assessments | Follow-up time points (months) |
|---|---|---|---|---|---|---|---|
| ART | Little (2021)51 | 2943 | Australia, Austria, Brazil, India, Italy, Poland, UK | 2004–07 | CABG: SITA vs. BITA | EQ-5D | B, 1, 5 |
| BBS | Østergaard (2016)50 | 120 | Denmark | 2002–04 | CABG: off-pump vs. on-pump | SF-36 | B, 3, 12, 96 |
| CARRPO | Damgaard (2011) | 331 | Denmark | 2002–05 | CABG: total arterial vs. conventional | SF-36 | B, 3, 11 |
| CORONARY | Lamy (2016) | 2850 | NR, worldwide | 2006–11 | CABG: off-pump vs. on-pump | EQ-5D, EQ-5D visual analogue | B, 1, 12, 60 |
| CRISP | Rogers (2014) | 98 | UK, India, Brazil, Canada, Germany, Italy | 2009–11 | CABG: off-pump vs. on-pump | EQ-5D | B, 4–8 weeks |
| CSP474 | Bakaeen (2012) | 725 | USA | 2003–09 | CABG: radial vs. SVG, residents vs. attendees | SAQ | B, 3, 12 |
| DOORS | Houlind (2012) | 900 | Denmark | 2005–08 | CABG: off-pump vs. on-pump | SF-36, EQ-5D | B, 6 |
| EXCEL | Baron (2017) | 896 | NR, worldwide | 2010–14 | CABG vs. PCI | SAQ, SF-12, PHQ-8 | B, 1, 12, 36 |
| FREEDOM | Abdallah (2013) | 935 | NR, worldwide | 2005–10 | CABG vs. PCI | SAQ | B, 1, 6, 12 |
| Magnuson (2013) | 911 | EQ-5D | |||||
| MOTIV-CABG | Perrotti (2016) | 217 | France | 2006–12 | CABG: MDD vs. no MDD | SF-36 | B, 1, 3, 6, 12 |
| ROOBY | Bishawi (2013) | 2127 | USA | 2002–07 | CABG: off-pump vs. on-pump | SAQ, VR-36 | B, 12 |
| STICH | Mark (2014) | 610 | NR, worldwide | 2002–07 | Medical therapy vs. medical therapy + CABG | KCCQ, SAQ, SF-12, SF-36 | B, 4, 12, 24, 36 |
| SYNTAX | Cohen (2011)Cohen (2014) Abdallah (2017) | 897 870 848 | Austria, Belgium, Denmark, Finland, France, Germany, Hungary, Italy, the Netherlands, Poland, Spain, Sweden, UK, USA | 2005–07 | CABG vs. PCI | SAQ, SF-36 EQ-5D SAQ, SF-36 | B, 1, 6, 12 B, 1, 6, 12, 36, 60 |
| n/a | Anastasiadis (2016) | 60 | Greece | 2014 | CABG: MiECC vs. cCPB | SF-36 | B, 1, 3 |
| n/a | Fakhrzad (2016) | 200 | Iran | 2014 | CABG vs. PCI | SF-36, SAQ | 1, 6 |
B, baseline; cCPB, conventional cardiopulmonary bypass; EQ-5D, EuroQol 5 Dimensions Questionnaire; HUI, Health utilities index; MDD, major depressive disorder; MiECC, minimally invasive extracorporeal circulation; NR, not reported; SVG, saphenous vein graft; PCI, percutaneous coronary intervention; PHQ-8, Patient Health Questionnaire-8; SAQ, Seattle Angina Questionnaire; SF-12, 12-item Short-Form Health Survey; SF-36, 36-item Short-Form Health Survey; SVG, saphenous vein graft; VR-36, Veteran versions of the Short Form.
When studies reported QoL scores stratified by multiple study comparators (e.g. on vs. off pump, total arterial vs. conventional grafting, minimally invasive vs. conventional cardiopulmonary bypass), we pooled the scores between the two groups according to the Cochrane methodology standards (Supplementary material online, Table S3). Finally, risk of bias (RoB) was assessed through the Cochrane RoB tool for RCTs.9
Outcomes
The primary outcome was mean scores and weighted mean differences of SAQ AF from pre- to post-operative time points. This was the a priori primary outcome because freedom from angina is one of the goals of CABG surgery. Secondary outcomes were mean scores and weighted mean differences of SAQ QoL, SF-36 PC, SF-36 MC, and EQ-5D over the duration of follow-up.
Statistical analyses
Continuous variables were extracted from the included trials as mean ± SD or median [interquartile range (IQR)]. Median and IQR were converted to mean ± SD if the mean values were not available and the median IQRs were available: median was approximated to mean and SD was calculated as IQR/1.35.10 Categorical variables were reported as frequencies (percentages). Data from all available cases were used for each trial; imputed values were not used for any of the follow-up time points.
A two-pronged approach was used to analyse all outcomes. First, we pooled the means of each score at 6 months, 1 year, and 3–5 years to describe the temporal trends of QoL over the follow-up periods. Second, we computed the weighted mean differences of each score from baseline to 1 year, and for our primary outcome we extended the analysis to 5 years. In both analyses, meta-analytic estimates were pooled using a random-effect model with the inverse-variance method, and results were presented as means or weighted mean differences and 95% confidence interval (CI). For computation of weighted mean differences, a conservative assumption was made regarding sample sizes during the follow-up: whenever a study did not report the sample size in any of the time points, it was a priori assumed to be equal to the baseline sample size. For weighted mean differences, we also computed the prediction intervals, according to the method proposed by Higgins et al.11 The prediction interval provides the range within which any further effect of CABG on QoL will be likely found.
Heterogeneity was assessed using I² and χ² tests. We considered significant heterogeneity if I² > 50% and the χ² P-value was <0.05. Publication bias was visualized with funnel plots and evaluated for symmetry with Egger's tests. Meta-regression was performed to assess the effects of covariates (sex, age, diabetes, and trial publication date) on changes in QoL over time. There were insufficient data to perform subgroup analyses by type of CABG procedure.
All P-values are two‐sided and P-values less than 0.05 were considered to indicate statistical significance. There was no pre-specified plan to adjust for multiple comparisons. Analyses and data modelling were performed with R-project (version 3.3.3 R project for Statistical Computing), using the following packages: ‘meta’, ‘stats’, ‘dmatar’, ‘robvis’, and ‘ggplot2’ for data visualization.
Results
Study and participant characteristics
Among the 1841 screened articles, 18 were included in this meta-analysis for a total of 16 538 patients in 15 RCTs. The sample sizes in the individual studies ranged from 60 to 2942. The studies included data from over 15 countries: 7 trials were multicentre, 5 were in Europe, 2 were in the USA, and 1 in Iran (Table 1).12–29 The most commonly reported QoL assessment tool was the SF-36, followed by the SAQ and EQ-5D.
Baseline patient characteristics are included in Table 2. The mean age ranged from 59 to 76 years and the majority of patients were male, ranging from 30% to 99.2%. More than a third of the patients suffered from diabetes, with some studies including only diabetic patients.12,24 A history of previous myocardial infarction was present in 37% of the patients.
Table 2.
Baseline characteristics
| First author et al. (year) | Patients (n) | Age (years) | Sex (%M) | Diabetes (%) | HTN (%) | COPD (%) | NYHA class II–IV (%) | CCS class II–IV (%) | Previous MI (%) | PVD (%) | LVEF ≤50% (%) | Previous CABG (%) |
|---|---|---|---|---|---|---|---|---|---|---|---|---|
| Abdallah et al. (2013) | 935 | 63 | 72 | 100 | — | 5.5 | — | — | 25.1 | 10.5 | — | — |
| Abdallah et al. (2017) | 848 | 64.8 | 79.4 | 28.8 | — | — | — | — | 34.6 | — | — | 0 |
| Anastasiadis et al. (2016) | 60 | 66.3 | 84.9 | 25 | 81.5 | — | — | — | — | — | — | — |
| Bakaeen et al. (2012) | 725 | 61.2 | 99.2 | 41.8 | 78.5 | — | — | 47.5 | 39.3 | — | — | — |
| Baron et al. (2017) | 896 | 65.8 | 78.2 | 28.6 | 76.3 | — | — | — | 16.9 | — | — | — |
| Bishawi et al. (2013) | 2127 | 62.8 | 99.4 | 43.1 | 86.1 | 20.6 | — | — | — | 15.8 | 5.6 | — |
| Cohen et al. (2011) | 897 | 65 | 78.9 | 28.5 | — | — | — | — | 33.8 | — | — | — |
| Cohen et al. (2014) | 870 | 64.9 | 79.4 | 27.6 | — | 9.2 | — | — | 33.3 | 10.5 | . | — |
| Damgaard et al. (2011) | 331 | 59 | 88.2 | 24.8 | 49.3 | — | 18.8 | 28.5 | — | — | 0 | — |
| Fakhrzad et al. (2016) | 200 | 60.23 | 63.5 | 39.5 | 34.5 | — | — | — | — | — | — | — |
| Houlind et al. (2012) | 900 | 75 | 77 | 20 | 71 | 9.7 | 54.5 | 65.5 | — | 13 | 5.2 | — |
| Lamy et al. (2016) | 2850 | 67.3 | 81.4 | 46.6 | 73.8 | — | — | — | 32 | 7.3 | 29.1 | 0 |
| Little et al. (2021)51 | 2943 | 63.5 | 85.7 | 24.0 | — | — | — | — | — | — | — | — |
| Magnuson et al. (2013) | 911 | 62.9 | 69.9 | 100 | — | 5.4 | — | — | 25.1 | 10.5 | — | 0 |
| Mark et al. (2014) | 610 | 60 | 88 | 39 | — | — | 89.3 | — | 76 | — | 100 | 4 |
| Østergaard et al. (2016)50 | 120 | 76 | 30 | 18.5 | 61 | — | — | — | — | — | — | — |
| Perrotti et al. (2016) | 217 | 67.1 | 86.2 | 30.9 | 60.4 | 1.8 | — | — | 28.1 | 8.6 | 3 | — |
| Rogers et al. (2014) | 98 | 76 | 77 | 24.5 | 80 | 13 | 29 | 28 | 70 | 12 | 5 | — |
CCS, Canadian Cardiovascular Society; COPD, chronic obstructive pulmonary disease; HTN, hypertension; M, male; MI, myocardial infarction; NYHA, New York Heart Association; PVD, peripheral vascular disease.
Disease-specific QoL
SAQ
Overall, the SAQ AF improved from a baseline score of 69 (95% CI: 66.6–71.5) to 91.4 (95% CI: 87.3–95.6) at 3–6 months (P < 0.01), and 92.9 (95% CI: 90.7–95.1) at 1 year (Supplementary material online, Table S2 and Figure S2). The weighted mean difference from baseline to 1 year was 24 (95% CI: 21.6–26.4) and 21.8 (95% CI: 17.3–26.4) at 5 years (Figure 2). In addition, SAQ QoL significantly improved from before CABG (47.2, 95% CI: 45–49.5) to 1 year after CABG (80.9, 95% CI: 77.1–84.7, P < 0.01) (Supplementary material online, Figure S3). Overall, the weighted mean difference from baseline to 1 year was 31.0 (95% CI: 27.5–34.6) (Figure 2). For both outcomes, prediction intervals were consistent with the point estimate.
Figure 2.
Forest plots showing pooled weighted mean differences of quality-of-life scores from baseline to 1-year follow-up. EQ-5D, EuroQol Questionnaire; QoL, quality of life; SAQ AF: Seattle Angina Questionnaire—angina frequency; SAQ QoL, Seattle Angina Questionnaire—quality of life; SF-36 PC, 36-item Short Form Health Survey (physical component); SF-36 MC: 36-item Short Form Health Survey (mental component).
Generic QoL
SF-36 physical and mental composite scores
Physical functioning of patients undergoing CABG also improved as measured by the SF-36 PC, whose pooled mean value increased from 47.4 (95% CI: 43.3–51.6) at baseline to 56.9 (95% CI: 49.4–64.5) at 1 year (P = 0.03) (Supplementary material online, Figure S4). The weighted mean difference from baseline to 1 year was 9.9 (95% CI: 7.1–12.8) (Figure 2). Conversely, SF-36 MC values measured pre-operatively did not show a statistically significant improvement from baseline 52.3 (95% CI: 47.5–57.1) to 60.8 (95% CI: 50.8–70.7, P = 0.13) at 1 year (Supplementary material online, Figure S5). The weighted mean difference from baseline to 1 year was 7.1 (95% CI: 4.2–10.0) (Figure 2). The prediction intervals showed that QoL assessed by the SF-36 PC and SF-36 MC could be either improved or worsened 1 year after CABG.
EQ-5D
Analysis of EQ-5D trends across the trials showed a significant improvement from 0.76 (95% CI: 0.74–0.78, P < 0.001) to 0.86 (95% CI: 0.85–0.97) at 1-year follow-up (Supplementary material online, Figure S6). The weighted mean difference from baseline to 1 year was 0.10 (95% CI: 0.06–0.14) (Figure 2). The prediction interval showed that QoL assessed by the EQ-5D favours improved QoL, but also includes the potential for worse QoL outcomes at 1 year after CABG.
Meta-regression
For the SAQ AF domain, age was directly associated with higher scores for the SAQ AF domain at 5-year follow-up (Supplementary material online, Table S4 and Figure S7). Likewise, age was also directly associated with higher scores for the SAQ QoL domain at 1 year. Trials published in later years reported more improvement in the SF-36 MC. Finally, for the EQ-5D, studies that had a higher proportion of males were associated with better QoL.
Risk of bias
The RoB assessment is shown in the Supplementary material online, Figure S8. Ten RCTs were at low RoB, six raised some concerns, and two were at high RoB. The highest RoB in the reported studies was due to lack of blinding among the research team when measuring the QoL outcomes (5 studies had some concerns and 1 had high concerns). No studies were excluded due to bias. There was no evidence of publication bias or a small-study effect based on the funnel plots and Egger's asymmetry tests (Supplementary material online, Figures S9–S13).
Discussion
In this meta-analysis, we evaluated the short- and long-term effects of CABG surgery on disease-specific and generic QoL in randomized clinical trials published within the last 10 years. This study includes both a descriptive study showing temporal trends in QoL after CABG surgery and a quantitative comparison from before surgery to up to 5 years after surgery. Overall, there was improvement in disease-specific QoL by 6 months, and this benefit was sustained up to 1, 3, and 5 years post-operatively across the SAQ AF and SAQ QoL domains of the SAQ.
Generic QoL (measured by the physical component of the SF-36 and the EQ-5D) also improved by 6 months, peaked at 1 year, and remained stable up to 5 years. Conversely, the mental component of the SF-36 showed an initial improvement at 6 months in comparison to the pre-operative period, but failed to further improve at 1 year and returned to baseline by 3 and 5 years. Overall, the improvement in the SF-36 MC was not robust, and could be related to the paucity of studies reporting psychological measures of QoL at 48–60 months post-operatively. Previous studies comparing QoL in CABG and PCI also demonstrated a larger difference in changes in physical functioning compared to mental health domains.5
The analysis of the temporal trends over the course of follow-up showed a continuous increase in QoL from 6 months to 1 year, which then plateaued out to the longest follow-up time point (5 years). This may suggest that maximal improvement in QoL is reached around the same time as full recovery from CABG surgery (∼1 year). Decreases in QoL at 6 months post-operatively could be directly related to the usual course following surgery or complications from the operation itself (i.e. prolonged length of stay in hospital or slow recovery), which could deleteriously impact QoL. The plateau in QoL between 1 and 5 years could be related to a combination of factors, including the stable treatment effect of CABG, as well as a reporting bias with fewer trials describing QoL data at the 3- and 5-year time points. Nevertheless, the absolute values recorded for generic QoL are consistent with other surgical30–32 and oncology specialties,33,34 and could represent the ceiling effect for patients living with advanced chronic diseases.
Patients reported the most improvement in the symptoms of angina after CABG surgery35 and the extent of this improvement was well beyond the threshold of what is considered a minimally clinically important difference. Indeed, we found an improvement of at least 20 points at 1 and 5 years, while a 10-unit change in SAQ is already considered clinically relevant.36,37 A plausible explanation for the improvement in angina could be the reduction of the ischaemic burden provided by CABG only.35 A comparable improvement to SAQ and EQ-5D was not found from either optimal medical therapy or percutaneous angioplasty.38–40 We also found a positive correlation between age and SAQ scores, which has been substantiated by other similar studies.41,42 Moreover, this evidence underscores the value of a patient's perspective on his or her own disease.
On the other hand, changes in SF-36 PC summary scores were less prominent and this evidence supports the hypothesis that angina relief after CABG occurs rapidly, whereas functional recovery is slower and less appreciable within the first few months of surgery. However, the mean change of SF-36 PC from baseline to post-operative assessment points was over the threshold for accepted 10-point change for clinical significance.43
It was not possible to contrast EQ-5D changes against approved clinically significant differences, as no such threshold has been validated within the cardiovascular field. However, if compared to the threshold for its general use,44,45 EQ-5D bore a clinically significant improvement of QoL after surgical revascularization.
Finally, despite the sparsity of studies and the between-study heterogeneity, the prediction intervals supported an improvement in QoL only for the SAQ AF at 1 and 5 years and for the SAQ QoL at 1 year, whereas prediction intervals suggested that QoL could be either lower or higher than baseline after CABG when generic QoL assessment tools were used. This suggests that a future study will be more likely to identify a significant improvement in QoL after CABG using the SAQ assessment tool rather than generic QoL instruments. This is consistent with a previously reported finding that generic QoL instruments are less sensitive to capturing significant changes in QoL than the disease-specific measures.46,47 A limitation of disease-specific measures is that they are inadequate for economic evaluations and calculating quality-adjusted life years, hence why the combination of disease-specific and generic measures is important. A strength of this study is that it includes patient populations that reflect current intra-operative and post-operative clinical management, as well as contemporary QoL outcome definitions and assessment.
Limitations
The results of the present meta-analysis must be interpreted within the context of common limitations in surgical randomized trials, including unmeasured confounders48 and lack of blinding of both the patient and the cardiac surgeon. A significant limitation of this study, and any study evaluating QoL over time, is that it only includes participants who are alive and free of major impairments such that they would prevent the completion of QoL questionnaires. As with all aggregate data analysis, the results may be influenced by factors not considered, such as differences in pre-, peri-, and post-operative care of patients. Statistical heterogeneity was high for the explored outcomes, but this was anticipated because the outcomes were continuous variables.49 An appropriate subgroup analysis regarding pre-operative variables or operative techniques (off-pump vs. on-pump surgery, multiple arterial grafting, minimally invasive CABG) was not possible given the paucity of studies reporting QoL for these different subgroups. Also, only five studies included race and ethnicity data on the individual samples and, because of the inconsistent categorization, it was not possible to conduct meta-regression on these variables. One of the limitations with calculating the weighted mean differences is that we did not have data on differences in sample sizes at each of the follow-up time points, so we had to make conservative assumptions about the loss to follow-up in some of the studies over time.
Conclusions
This meta-analysis of randomized evidence found that CABG significantly improved disease-specific QoL in both short- and long-term time points, with the largest reduction in the AF over time.
Supplementary Material
Acknowledgement
We would like to acknowledge Dr Antonio Nenna for his involvement in abstract screening.
Contributor Information
Ruth Masterson Creber, Division of Health Informatics, Department of Healthcare Policy and Research, Weill Cornell Medicine, New York, NY, USA.
Arnaldo Dimagli, Bristol Heart Institute, University of Bristol, Bristol, UK.
Cristiano Spadaccio, Institute of Cardiovascular and Medical Sciences, University of Glasgow, UK; Lancashire Cardiac Center, Blackpool Victoria Teaching Hospital, Blackpool, UK.
Annie Myers, Division of Health Informatics, Department of Healthcare Policy and Research, Weill Cornell Medicine, New York, NY, USA.
Marco Moscarelli, Department of Cardiac Surgery, Imperial College London, London, UK.
Michelle Demetres, Samuel J. Wood Library and C.V. Starr Biomedical Information Center, Weill Cornell Medicine, New York, NY USA.
Matthew Little, Health Economics Research Centre, Nuffield Department of Population Health, University of Oxford, UK.
Stephen Fremes, Sunnybrook Health Sciences Center, University of Toronto, Toronto, Canada.
Mario Gaudino, Department of Cardiothoracic Surgery, Weill Cornell Medicine, New York, NY, USA.
Funding
R.M.C. receives funding from National Institute of Nursing Research (NINR) (R00NR016275) and National Heart Lung and Blood Institute (NHLBI) (R01HL152021). A.G. receives funding from NHLBI (R01HL152021).
Conflict of interest
The authors have no conflicts to disclose.
Data availability
The data underlying this article will be shared on reasonable request to the corresponding author.
References
- 1. Head SJ, Milojevic M, Taggart DP, Puskas JD. Current practice of state-of-the-art surgical coronary revascularization. Circulation 2017;136:1331–1345. [DOI] [PubMed] [Google Scholar]
- 2. Fernandez FG, Shahian DM, Kormos R, Jacobs JP, D'Agostino RS, Mayer Jr JE et al. The Society of Thoracic Surgeons National Database 2019 Annual Report. Ann Thorac Surg 2019;108:1625–1632. [DOI] [PubMed] [Google Scholar]
- 3. Gaudino M, Hameed I, Farkouh ME, Rahouma M, Naik A, Robinson NB et al. Overall and cause-specific mortality in randomized clinical trials comparing percutaneous interventions with coronary bypass surgery: a meta-analysis. JAMA Intern Med 2020;180:1638–1646. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 4. Head SJ, Milojevic M, Daemen J, Ahn JM, Boersma E, Christiansen EH et al. Mortality after coronary artery bypass grafting versus percutaneous coronary intervention with stenting for coronary artery disease: a pooled analysis of individual patient data. Lancet 2018;391:939–948. [DOI] [PubMed] [Google Scholar]
- 5. Takousi MG, Schmeer S, Manaras I, Olympios CD, Makos G, Troop NA. Health-related quality of life after coronary revascularization: a systematic review with meta-analysis. Hellenic J Cardiol 2016;57:223–237. [DOI] [PubMed] [Google Scholar]
- 6. Schmidt-RioValle J, Abu Ejheisheh M, Membrive-Jiménez MJ, Suleiman-Martos N, Albendín-García L, Correa-Rodríguez M et al. Quality of life after coronary artery bypass surgery: a systematic review and meta-analysis. Int J Environ Res Public Health 2020;17:8439. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 7. Kaambwa B, Gesesew HA, Horsfall M, Chew D. Quality of life changes in acute coronary syndromes patients: a systematic review and meta-analysis. Int J Environ Res Public Health 2020;17:6889. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 8. Liberati A, Altman DG, Tetzlaff J, Mulrow C, Gotzsche PC, Ioannidis JPA et al. The PRISMA statement for reporting systematic reviews and meta-analyses of studies that evaluate healthcare interventions: explanation and elaboration. BMJ 2009;339:b2700. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 9. Higgins JPT, Altman DG, Gøtzsche PC, Jüni P, Moher D, Oxman AD et al. The Cochrane Collaboration's tool for assessing risk of bias in randomised trials. BMJ 2011;343:d5928–d5928. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 10. Higgins JPT, Li T, Deeks JJ. Chapter 6: Choosing effect measures and computing estimates of effect. In: Higgins JPT, Thomas J, Chandler J, Cumpston M, Li T, Page MJ, Welch VA, eds. Cochrane Handbook for Systematic Reviews of Interventions version 6.2 (updated Febrary 2021). Cochrane, 2021. Available from https://training.cochrane.org/handbook/current/chapter-06. [Google Scholar]
- 11. Higgins JPT, Thompson SG, Spiegelhalter DJ. A re-evaluation of random-effects meta-analysis. J R Stat Soc Ser A Stat Soc 2009;172:137–159. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 12. Abdallah MS, Wang K, Magnuson EA, Spertus JA, Farkouh ME, Fuster V et al. ; FREEDOM Trial Investigators. Quality of life after PCI vs. CABG among patients with diabetes and multivessel coronary artery disease: a randomized clinical trial. JAMA 2013;310:1581–1590. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 13. Abdallah MS, Wang K, Magnuson EA, Osnabrugge RL, Pieter Kappetein A, Morice MC et al. Quality of life after surgery or DES in patients with 3-vessel or left main disease. J Am Coll Cardiol 2017;69:2039–2050. [DOI] [PubMed] [Google Scholar]
- 14. Anastasiadis K, Antonitsis P, Kostarellou G, Kleontas A, Deliopoulos A, Grosomanidis V et al. Minimally invasive extracorporeal circulation improves quality of life after coronary artery bypass grafting. Eur J Cardiothorac Surg 2016;50:1196–1203. [DOI] [PubMed] [Google Scholar]
- 15. Bakaeen FG, Sethi G, Wagner TH, Kelly R, Lee K, Upadhyay A et al. Coronary artery bypass graft patency: residents versus attending surgeons. Ann Thorac Surg 2012;94:482–488; discussion 488. [DOI] [PubMed] [Google Scholar]
- 16. Baron SJ, Chinnakondepalli K, Magnuson EA, Kandzari DE, Puskas JD, Ben-Yehuda O et al. Quality-of-life after everolimus-eluting stents or bypass surgery for left-main disease: results from the EXCEL trial. J Am Coll Cardiol 2017;70:3113–3122. [DOI] [PubMed] [Google Scholar]
- 17. Bishawi M, Shroyer AL, Rumsfeld JS, Spertus JA, Baltz JH, Collins JF et al. ; Va #517 Randomized on/off Bypass (Rooby) Study Group. Changes in health-related quality of life in off-pump versus on-pump cardiac surgery: Veterans Affairs Randomized On/Off Bypass trial. Ann Thorac Surg 2013;95:1946–1951. [DOI] [PubMed] [Google Scholar]
- 18. Cohen DJ, Van Hout B, Serruys PW, Mohr FW, Macaya C, den Heijer P et al. ; Synergy between PCI with Taxus and Cardiac Surgery Investigators. Quality of life after PCI with drug-eluting stents or coronary-artery bypass surgery. N Engl J Med 2011;364:1016–1026. [DOI] [PubMed] [Google Scholar]
- 19. Cohen DJ, Osnabrugge RL, Magnuson EA, Wang K, Li H, Chinnakondepalli K et al. ; SYNTAX Trial Investigators. Cost-effectiveness of percutaneous coronary intervention with drug-eluting stents versus bypass surgery for patients with 3-vessel or left main coronary artery disease: final results from the Synergy Between Percutaneous Coronary Intervention With TAXUS and Cardiac Surgery (SYNTAX) trial. Circulation 2014;130:1146–1157. [DOI] [PubMed] [Google Scholar]
- 20. Damgaard S, Lund JT, Lilleør NB, Perko MJ, Madsen JK, Steinbrüchel DA. Comparably improved health-related quality of life after total arterial revascularization versus conventional coronary surgery—Copenhagen Arterial Revascularization Randomized Patency and Outcome Trial. Eur J Cardiothorac Surg 2011;39:478–483. [DOI] [PubMed] [Google Scholar]
- 21. Fakhrzad N, Goudarzi R, Barouni M, Kojuri J, Jahani Y. Examining the health-related quality of life after coronary artery bypass grafting and percutaneous coronary intervention in Iran via SF-36 and SAQ. Int Cardiovasc Res J 2015;10:123–128. [Google Scholar]
- 22. Houlind K, Kjeldsen BJ, Madsen SN, Rasmussen BS, Holme SJ, Nielsen PH et al. ; DOORS Study Group. On-pump versus off-pump coronary artery bypass surgery in elderly patients: results from the Danish on-pump versus off-pump randomization study. Circulation 2012;125:2431–2439. [DOI] [PubMed] [Google Scholar]
- 23. Lamy A, Devereaux PJ, Prabhakaran D, Taggart DP, Hu S, Straka Z et al. ; CORONARY Investigators. Five-year outcomes after off-pump or on-pump coronary-artery bypass grafting. N Engl J Med 2016;375:2359–2368. [DOI] [PubMed] [Google Scholar]
- 24. Magnuson EA, Farkouh ME, Fuster V, Wang K, Vilain K, Li H et al. FREEDOM Trial Investigators, Cost-effectiveness of percutaneous coronary intervention with drug eluting stents versus bypass surgery for patients with diabetes mellitus and multivessel coronary artery disease: results from the FREEDOM trial. Circulation 2013;127:820–831. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 25. Mark DB, Knight JD, Velazquez EJ, Wasilewski J, Howlett JG, Smith PK et al. Quality-of-life outcomes with coronary artery bypass graft surgery in ischemic left ventricular dysfunction: a randomized trial. Ann Intern Med 2014;161:392–399. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 26. Østergaard B, Holbæk E, Sørensen J, Steinbrüchel D. Health-related quality of life after off-pump compared with on-pump coronary bypass grafting among elderly high-risk patients: a randomized trial with eight years of follow-up. Eur J Cardiovasc Nurs 2016;15:126–133. [DOI] [PubMed] [Google Scholar]
- 27. Perrotti A, Mariet A-S, Durst C, Monaco F, Vandel P, Monnet E et al. Relationship between depression and health-related quality of life in patients undergoing coronary artery bypass grafting: a MOTIV-CABG substudy. Qual Life Res 2016;25:1433–1440. [DOI] [PubMed] [Google Scholar]
- 28. Rogers CA, Pike K, Campbell H, Reeves BC, Angelini GD, Gray A et al. Coronary artery bypass grafting in high-RISk patients randomised to off- or on-pump surgery: a randomised controlled trial (the CRISP trial). Health Technol Assess (Rockv) 2014;18:v–xx, 1-157. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 29. Wagner TH, Sethi G, Holman W, Lee K, Bakaeen FG, Upadhyay A et al. Costs and quality of life associated with radial artery and saphenous vein cardiac bypass surgery: results from a Veterans Affairs multisite trial. Am J Surg. 2011;202:532–535. [DOI] [PubMed] [Google Scholar]
- 30. Bendixen M, Jørgensen OD, Kronborg C, Andersen C, Licht PB. Postoperative pain and quality of life after lobectomy via video-assisted thoracoscopic surgery or anterolateral thoracotomy for early stage lung cancer: a randomised controlled trial. Lancet Oncol 2016;17:836–844. [DOI] [PubMed] [Google Scholar]
- 31. Ichimura H, Kobayashi K, Gosho M, Nakaoka K, Yanagihara T, Ueda S et al. Trajectory and profile of quality of life in patients undergoing lung resection for lung cancer during hospitalization according to the EQ-5D. Gen Thorac Cardiovasc Surg 2021;69:1204–1213. [DOI] [PubMed] [Google Scholar]
- 32. Fuller JC, Levesque PA, Lindsay RW. Assessment of the EuroQol 5-Dimension Questionnaire for detection of clinically significant global health-related quality-of-life improvement following functional septorhinoplasty. JAMA Facial Plast Surg 2017;19:95–100. [DOI] [PubMed] [Google Scholar]
- 33. Basch E, Deal AM, Kris MG, Scher HI, Hudis CA, Sabbatini P et al. Symptom monitoring with patient-reported outcomes during routine cancer treatment: a randomized controlled trial. J Clin Oncol 2016;34:557–565. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 34. Noel CW, Lee DJ, Kong Q, Xu W, Simpson C, Brown D et al. Comparison of health state utility measures in patients with head and neck cancer. JAMA Otolaryngol Head Neck Surg 2015;141:696–703. [DOI] [PubMed] [Google Scholar]
- 35. Doenst T, Haverich A, Serruys P, Bonow RO, Kappetein P, Falk V et al. PCI and CABG for treating stable coronary artery disease: JACC review topic of the week. J Am Coll Cardiol 2019;73:964–976. [DOI] [PubMed] [Google Scholar]
- 36. Dougherty CM, Dewhurst T, Nichol WP, Spertus J. Comparison of three quality of life instruments in stable angina pectoris: Seattle Angina Questionnaire, Short Form Health Survey (SF-36), and Quality of Life Index-Cardiac Version III. J Clin Epidemiol 1998;51:569–575. [DOI] [PubMed] [Google Scholar]
- 37. Seki S, Kato N, Ito N, Kinugawa K, Ono M, Motomura N et al. Validity and reliability of Seattle Angina Questionnaire Japanese version in patients with coronary artery disease. Asian Nurs Res 2010;4:57–63. [DOI] [PubMed] [Google Scholar]
- 38. Al-Lamee R, Thompson D, Dehbi H-M, Sen S, Tang K, Davies J et al. Percutaneous coronary intervention in stable angina (ORBITA): a double-blind, randomised controlled trial. Lancet 2018;391:31–40. [DOI] [PubMed] [Google Scholar]
- 39. Weintraub WS, Spertus JA, Kolm P, Maron DJ, Zhang Z, Jurkovitz C et al. ; COURAGE Trial Research Group. G. B. J. Mancini. Effect of PCI on quality of life in patients with stable coronary disease. N Engl J Med 2008;359:677–687. [DOI] [PubMed] [Google Scholar]
- 40. Spertus JA, Jones PG, Maron DJ, Mark DB, O'Brien SM, Fleg JL et al. ; ISCHEMIA-CKD Research Group. Health Status after Invasive or Conservative Care in Coronary and Advanced Kidney Disease. N Engl J Med 2020;382:1619–1628. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 41. Masoudi FA, Rumsfeld JS, Havranek EP, House JA, Peterson ED, Krumholz HM et al. ; Cardiovascular Outcomes Research Consortium. Age, functional capacity, and health-related quality of life in patients with heart failure. J Card Fail 2004;10:368–373. [DOI] [PubMed] [Google Scholar]
- 42. Longmore RB, Spertus JA, Alexander KP, Gosch K, Reid KJ, Masoudi FA et al. Angina frequency after myocardial infarction and quality of life in older versus younger adults: the Prospective Registry Evaluating Myocardial Infarction: Event and Recovery study. Am Heart J 2011;161:631–638. [DOI] [PubMed] [Google Scholar]
- 43. Grady KL, Lee R, Subačius H, Malaisrie SC, McGee Jr EC, Kruse J et al. Improvements in health-related quality of life before and after isolated cardiac operations. Ann Thorac Surg 2011;91:777–783. [DOI] [PubMed] [Google Scholar]
- 44. Agency for Healthcare Research and Quality . Guidelines and Measures. https://www.ahrq.gov/gam/index.html (19 April 2021). [Google Scholar]
- 45. Canadian Pharmacists Association. . https://www.e-therapeutics.ca/login?auth=fail (19 April 2021). [Google Scholar]
- 46. Marshall Kate H, D'Udekem Yves, Sholler Gary F, Opotowsky Alexander R, Costa Daniel SJ, Sharpe Louise et al. Health-related quality of life in children, adolescents, and adults with a Fontan circulation: a meta-analysis. J Am Heart Assoc 2020;9:e014172. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 47. Whitehead SJ, Ali S. Health outcomes in economic evaluation: the QALY and utilities. Br Med Bull 2010;96:5–21. [DOI] [PubMed] [Google Scholar]
- 48. Gaudino M, Di Franco A, Rahouma M, Tam DY, Iannaccone M, Deb S et al. Unmeasured confounders in observational studies comparing bilateral versus single internal thoracic artery for coronary artery bypass grafting: a meta-analysis. J Am Heart Assoc 2018;7:e008010. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 49. Alba AC, Alexander PE, Chang J, MacIsaac J, DeFry S, Guyatt GH. High statistical heterogeneity is more frequent in meta-analysis of continuous than binary outcomes. J Clin Epidemiol 2016;70:129–135. [DOI] [PubMed] [Google Scholar]
- 50. Østergaard B, Holbæk E, Sørensen J, Steinbüchel D. Health-related quality of life after off-pump compared with on-pump coronary bypass grafting among elderly high-risk patients: a randomized trial with eight years of follow-up. Eur J Cardiovasc Nurs 2016;15:126–133. [DOI] [PubMed] [Google Scholar]
- 51. Little M, Gray AM, Altman DG, Benedetto U, Flather M, Gerry S et al. ; Arterial Revascularization Trial Investigators. Cost-effectiveness of bilateral versus single internal thoracic artery grafts at ten years. Eur Heart J Qual Care Clin Outcomes 2021 Jan;27:qcab004. [DOI] [PMC free article] [PubMed] [Google Scholar]
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The data underlying this article will be shared on reasonable request to the corresponding author.