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Eur J Cardiothorac Surg 2003;24:750-756
© 2003 Elsevier Science NL

Changes in health-related quality of life and functional capacity following coronary artery bypass graft surgery

^a Department of Cardiothoracic Surgery, Tampere University Hospital, Tampere, Finland
^b Rehabilitation Foundation, Helsinki, Finland
^c Department of Psychology, University of Helsinki, Helsinki, Finland
^d School of Public Health, University of Tampere, Tampere, Finland

Received 18 April 2003; received in revised form 14 June 2003; accepted 19 June 2003.

^* Corresponding author. Tel.: +358-3-247-4881
e-mail: otsojarvinen{at}koti.soon.fi

	Abstract

Top Abstract 1. Introduction 2. Methods 3. Results 4. Discussion References

 
Objective: Improvement in survival and quality of life are the primary indications for coronary artery bypass graft (CABG) operations. Among elderly patients the main goal of surgery is not necessarily to prolong life, but to improve the health-related quality of life. Factors associated with mortality and morbidity following CABG surgery have been well defined, but the quality of life and functional capacity in elderly patients undergoing CABG are poorly documented. The aim here was to investigate changes in health-related quality of life, overall performance status and symptomatic status during 1 year after CABG surgery. Methods: Comprehensive data on 508 CABG patients were prospectively collected, including preoperative risk factors and postoperative morbidity in a surgical center and in all eighteen secondary referral hospitals up to discharge. The RAND-36 Health Survey (RAND-36) was used as indicator of quality of life. The primary outcome was change in the physical component summary, mental component summary and General Health summary scores from the RAND-36. Karnofsky dependency category was used to assess overall performance status, and symptomatic status was estimated according to New York Heart Association (NYHA) class. All assessments were made preoperatively and repeated 12 months later. Analysis was based on three age groups: 64 years or less (282 patients), 65–74 years (175 patients), and 75 or more years (51 patients). Results: Thirty-day and 1-year survival rates were 98.2 and 96.7%, respectively. A great majority (86.4%) of the patients recovered without major complication. In all, the present data showed significant improvement in all eight domains of QOL as well as in functional capacity and NYHA class during the 1st year after CABG. However, the mean change in RAND-36 Mental Component Summary scores among patients aged 75 years or more did not reach a statistically significant level (P=0.097) and they had significantly minor improvement as compared to younger patients (P<0.05). Moreover, their General Health score improvement was poorer and statistically insignificant (P=0.817). Conclusions: Elderly patients not only have higher mortality and morbidity but also derive less benefit from CABG regarding certain aspects of QOL.

Key Words: Coronary artery bypass • Outcome • Quality of life • Functional capacity • Elderly

	1. Introduction

Top Abstract 1. Introduction 2. Methods 3. Results 4. Discussion References

 
Improvements in survival and quality of life are the primary indications for coronary artery bypass graft (CABG) operations [1]. Factors associated with survival following CABG surgery have been well defined. A number of risk indices have been developed for the prediction of postoperative mortality [2,3] and some solely for the prediction of morbidity [4,5]. However, there are limited data available to help clinicians identify patients likely to experience improvement or decrement in their overall quality of life following CABG surgery. Although the operation relieves angina, this reduction does not directly translate into quality of life improvement following surgery, since multiple physical and psychological factors may be involved.

In the past two decades, the median age of patients selected for CABG surgery has increased [6,7]. The elderly are a challenging group of patients undergoing surgical procedures. Their functional reserve capacity is diminished compared with younger patients [8] and they are more likely to have preoperative comorbid conditions [9]. In this group of patients life expectancy is also limited by natural factors, so that the gain in added life years by operative treatment is – naturally – limited. Although several publications have documented operative results in the elderly, there is a lack of data on quality of life in this group.

In the present prospective study we assessed in detail changes in health-related quality of life (RAND-36), overall performance status (Karnofsky score) and symptomatic status (New York Heart Association, NYHA class) during the 1st year following CABG surgery. Special interest was focused on the postoperative benefits for elderly patients.

	2. Methods

Top Abstract 1. Introduction 2. Methods 3. Results 4. Discussion References

 
2.1. Procedure and subjects
The data were obtained from Tampere University Hospital between May 2, 1999 and November 30, 2000. The cohort comprised 508 patients who underwent isolated CABG. The study was approved by the institutional review board of Tampere University Hospital and each patient gave written informed consent to participate. There were 420 (82.7%) male patients in the sample. Age range was from 34 to 92 years (median 63). Three hundred and ninety-eight (78.3%) of the procedures were performed electively, 108 (21.3%) urgently and two (0.4%) as emergencies. Four hundred and fifty-three (89.2%) patients underwent bypass grafting through a sternotomy incision with cardiopulmonary bypass (CPB; on-pump) and 55 (10.8%) were operated without CPB (off-pump).

During the primary hospital stay a comprehensive pre-, peri- and postoperative medical data body was collected. A summary of the preoperative data are shown in Table 1. Most patients were discharged on the 6th day (median) after the operation to the local district hospital, where they were kept for another 6 days (as a median). The data from these secondary discharge hospitals were collected by referring physicians and sent to the first author (O.J.) for analysis. All outcome events, including 30-day mortality and complications, were recorded for joint analysis with the primary hospital data. Major postoperative complications included mortality, stroke, mediastinitis, sepsis, low output syndrome, prolonged ventilatory support (>36 h), acute renal failure requiring dialysis, perioperative myocardial infarction (a new Q-wave in the electrocardiogram or a peak level of CK-MB more than 150 µmol/l), pulmonary embolism and severe cardiac failure or severe ventricular arrhythmia requiring ICU or CCU stay in the primary or secondary referral hospital. Atrial fibrillation was recorded as a minor complication.

The follow-up questionnaire including the same measures was mailed to the participants 1 year after the by-pass operation. Seventeen (3.3%) had died during this postoperative period. Four hundred and sixty-five (94.7%) of the 491 surviving patients returned the follow-up questionnaire, mean time of follow-up being 12.6 (SD 1.2) months. Compared with the 465 patients who completed the form, those 26 patients who did not complete it were younger (median age 54 versus 63 years, P=0.006). However, there were no significant differences in the majority of variables, including sex, Euroscore risk sum, priority of operation, or in the NYHA class.

We used the Finnish adaptation of the RAND-36 generic health-related quality of life scale, for which there are reference values available for the Finnish population [10]. The RAND-36 is a widely used and validated scale which yields scores for eight dimensions of health-related quality of life: (1) general health; (2) physical functioning; (3) role functioning/physical; (4) bodily pain; (5) emotional well-being; (6) role functioning/emotional; (7) social functioning; and (8) energy [11,12]. The scores for each domain range from 0 to 100, 0 being the poorest and 100 the best possible health status. To reduce the number of outcome variables two summary scores can also be used: the physical component summary (PCS) equals the mean value of the physical sub-scales (1–4) while the mental component summary (MCS) equals the mean value of more psychical sub-scales (5–8) [13–15]. We also used the RAND-36 first item for ’general health’ separately (Fig. 1) . The main content of this item is worded: "In general, would you say your health is: excellent, very good, good, fair, poor?".

View larger version (9K): [in this window] [in a new window]   Fig. 1. General health scores (RAND-36) preoperatively and 1 year after coronary bypass grafting by age.

	3. Results

Top Abstract 1. Introduction 2. Methods 3. Results 4. Discussion References

 
Thirty-day and 1 year survival rates were 98.2% (nine deaths) and 96.7% (17 deaths), respectively. Both 30-day (55.6%) and subsequent (62.5%) deaths occurred mainly for cardiac-related reasons. Major postoperative adverse events were as follows: prolonged hospitalization (more than 3 weeks); 7.9%, perioperative myocardial infarction; 2.6%, stroke; 2.0%, mediastinitis; 1.4%, and impaired renal function requiring dialysis; 1.0%. A great majority (86.4%) of the patients recovered without any major complication. In all, atrial fibrillation was the most common postoperative complication, occurring in 169 patients (33.3%). There was an obvious tendency to more adverse events among the elderly in that 9.9, 14.3 and 31.4% of patients aged under 65 years, 65–74 years and 75 or more years, respectively, had major complication before discharge home (P<0.001). Likewise 30-day and 1-year mortalities were associated with age (P=0.029, P=0.095); 0.7 and 2.1% in the youngest, 2.3 and 4.0% in the middle age, and 5.9 and 7.8% in the oldest age group, respectively.

The study sample evinced depressed preoperative health status in all eight dimensions of the RAND-36 as compared to the general Finnish population (Table 3). All these health scores improved significantly (P<0.001) following CABG surgery, approaching the values in the general population. Moreover, emotional well-being and energy reached even higher scores.

Karnofsky performance status score improved from preoperative 70% to postoperative 90% (mode) at 1 year (P<0.001, Fig. 2) . In 70.5% of the patients the Karnofsky score improved by at least 10%. Patient's age or sex played no significant role in the magnitude of the improvement.

View larger version (16K): [in this window] [in a new window]   Fig. 2. Functional status (Karnofsky score) preoperatively and 1 year after coronary bypass grafting.

	4. Discussion

Top Abstract 1. Introduction 2. Methods 3. Results 4. Discussion References

 
This study evaluated the impact of CABG on improvement in various aspects of quality of life and functional capacity during 1 year after the operation. Special interest was focused on an analysis of the benefits for elderly patients. CABG surgery on elderly patients has become very common, and nowadays more than one in four patients operated on in Western countries are over 70 years old [17]. Consequently, also the definition of elderly in the literature has gradually risen from 65 to 80 years or older. Age greater than 70 years [4] or 80 years [3] is reported to be a prominent predictive preoperative factor for increased morbidity after CABG. Tu and associates found the relative mortality risk in the short term after CABG to increase to 2.1 for patients between 65 and 74 years of age and to 3.8 for those older than 75 years [18]. Although factors associated with morbidity and mortality following CABG surgery have been defined, only scattered data are available regarding QOL, overall performance status and functional outcome in elderly patients. In our study, we set the age of 75 years as the lower cut-off for the oldest age group, since only 1.6% of the patients were 80 or more years old.

NYHA functional class has been used by some authors as an indicator for postoperative QOL [9]. The usefulness of this, however, is restricted by the fact that it does not consider functional limitations due to other than cardiac disease. Thus, a patient who has achieved an excellent cardiac functional outcome after CABG could still be debilitated with poor QOL. A variety of health measurement tools have therefore been developed over the last decade for the purpose of quantifying and differentiating between different health states [19]. We chose the Finnish version of the RAND-36 Health Survey questionnaire, because it has been carefully adapted to Finnish populations and yields population-based reference values, which are derived from the randomly selected sample from the Finnish Population Register [10]. This sample consisted of 2060 persons aged 18–79 years and the results were weighted against the age and gender distribution of the Finnish general population. The generic health-related QOL measure has also previously been used to evaluate health status in general population surveys [20], and to determine the effectiveness of medical treatments in patients with angina [21], and more recently to evaluate the impact of mitral valve surgery [22] and CABG surgery [23,24] on patients’ QOL.

The present study demonstrated significant improvement in all eight dimensions of health-related QOL during the 1st year after CABG. Previous studies have found favourable and in some cases equal results in an ageing population as in a younger population in terms of health-related QOL after CABG [8]. On the other hand, some previous research has also indicated that older patients run an increased risk of postoperative psychiatric complications and cognitive decline [25]. From this perspective it is of note that the positive change in the physical aspects of QOL (PCS) was highly significant also in the oldest age group in our study, i.e. patients aged 75 or more years, and comparable with younger patients, whereas the mean improvement in psycho-social aspects of QOL (MCS) seemed to be significantly smaller as compared to younger groups. Moreover, a tendency towards less marked improvement in RAND-36 scores among the elderly was also seen in general health perceptions, as patients aged 75 or more years reported only minor improvement following surgery. These results could be explained by more prevalent comorbidity in the oldest patients. In contrast to somewhat pessimistic interpretations of the possible benefits for women regarding QOL [24], our results indicate that women benefit equally well from CABG.

We used the Karnofsky dependency classification to reflect the degree of help the patients needed. The Karnofsky dependency scale was originally designed to assess overall performance status in cancer patients [16], but it has since been used by some authors in cardiac patients [8,9]. The Karnofsky performance status of patients after CABG has received little attention, possibly because many patients are well functional both before and after surgery. Nonetheless, Karnofsky dependency classification here revealed a significant shift towards more independent functioning in daily activities in all age groups.

In accord with reports in the literature, higher age was significantly associated with higher mortality and morbidity in our data [3,4]. Higher morbidity and mortality in the elderly may reflect an increased presence of comorbidities as well as a lack of functional reserves among these patients. However, recovery without any major complication was likely at a 75% level even in those aged 75 or more years.

CABG treats the manifestations of coronary artery disease and angina therefore often returns as coronary disease progresses. The risk of recurring angina is low for the first 5 years after the operation and then begins to rise, seemingly related to late closure of bypass conduits [1]. Of particular note is that almost one fourth of the eldest patients in our material reported a return of angina (NYHA functional classes III or IV) during 1 year following the operation, this being significantly more than the 6% reported by the patients in the youngest age group. This may partially reflect the more extensive nature of coronary artery disease in the elderly, but also more comorbidities and non-cardiac disorders which may have impacted on elderly patients’ views of their general health and thus on the reported NYHA class.

In addition to the prospective design and relatively large number of patients included in this study, the reliability of our results is underlined by the fact that the relevant medical and clinical variables were carefully recorded for the analysis. Data on primary hospital care were complete, and our data also included events in the secondary referral hospitals, which is important, since only 2.4% of the patients were discharged straight home. A comprehensive battery of previously validated health measurement tools were used and all assessments were made preoperatively and repeated 12 months later. The response rate to our follow-up questionnaire was good (94.7%), and except for younger age, no other differences were found between the non-responders and responders in their preoperative clinical characteristics such as sex, Euroscore risk sum, priority of operation or NYHA class.

This notwithstanding, several potential limitations of this study should be discussed. First, there were a large number of patients who refused or were unable to complete the baseline survey prior to CABG and were thus excluded from this psycho-social follow-up study. Excluded patients were 5 years older and acutely ill and they were often operated urgently or in emergencies. The extent to which the findings can be generalized to all patients undergoing CABG may thus be questioned. Secondly, the hypothesis was that the changes in QOL would result from the intervening CABG. However, other major life events may have taken place during the year between assessments. Moreover, there is a lack of ‘golden standards’ for clinically important change in QOL scores in CABG surgery patients. Third, the NYHA class reported by the patient at 1 year may be of limited value only, since we were not able to confirm that symptoms experienced were a result of myocardial ischaemia and not of other comorbidities such as chronic obstructive airways disease. Finally, 1-year follow-up is still a relatively short period to evaluate long-range outcomes and stability of quality of life after the CABG operation.

In conclusion, a majority of patients experience significant improvement in their QOL and functional capacity during the 1st year after CABG, as measured by the RAND-36 questionnaire, Karnofsky dependency category and NYHA functional class. Men and women benefit equally well from CABG. In contrast to most previous reports, we found that patients aged more than 75, who are often suboptimal candidates for CABG, not only have higher mortality and morbidity but are also likely to derive less benefit from CABG in terms of certain aspects of QOL. It is therefore important in clinical practice to consider the age-related aspects of outcome, particularly when the main goal of surgery is to improve QOL.

	References

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This Article Abstract Full Text (PDF) Alert me when this article is cited Alert me if a correction is posted Citation Map Services Email this article to a friend Similar articles in this journal Similar articles in PubMed Alert me to new issues of the journal Add to Personal Folders Download to citation manager Author home page(s): Matti R. Tarkka Permission Requests Citing Articles Citing Articles via HighWire Citing Articles via Google Scholar Google Scholar Articles by Järvinen, O. Articles by Tarkka, M. R. Search for Related Content PubMed PubMed Citation Articles by Järvinen, O. Articles by Tarkka, M. R. Related Collections Cardiac - other Coronary disease