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Eur J Cardiothorac Surg 2008;34:1009-1015. doi:10.1016/j.ejcts.2008.08.003
Copyright © 2008, European Association for Cardio-thoracic Surgery. Published by Elsevier. All rights reserved.
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Changes in quality of life, physical activity, and symptomatic status one year after myocardial revascularization for stable angina

Athanasios L.P. Markou, Armand van der Windt, Henri A. van Swieten, Luc Noyez*

Heart Center, Radboud University Nijmegen, Department of Cardio-Thoracic Surgery – 677, PO Box 9101, 6500 HB Nijmegen, The Netherlands

Received 29 May 2008; received in revised form 17 July 2008; accepted 4 August 2008.

* Corresponding author. Tel.: +31 24 3613711; fax: +31 24 3540129. (Email: l.noyez{at}thorax.umcn.nl).


   Abstract
Top
 Abstract
1. Introduction
 2. Patients and methods
 3. Results
 4. Discussion
 5. Conclusion
 Appendix A
 References
 
Background: This study investigates changes of quality of life (QOL), physical activity (PA) and symptomatic status (NYHA) at one-year post-coronary artery bypass grafting (CABG). Methods: Of 568 patients undergoing a primary isolated CABG for stable angina (NYHA <IV) pre- and 1-year postoperative data on QOL, PA, and NYHA were complete. Studied outcomes were changes in QOL, EuroQoL questionnaire, PA, the Corpus Christi Heart Project criteria and NYHA. Analysis was based on three age groups. Group A, age <65 years: 285 patients, group B, 65–74 years: 210 patients, and group C, age ≥75 years: 73 patients. Results: There is a similar, significant decrease of NYHA class (1.4) for the three groups (p < 0.0005). An overall significant improvement for QOL and PA is however different in the three subgroups. PA improvement is not significant in group C (p = 0.74), significant in group B (p = 0.005) and in group A (p < 0.0005). For the QOL, group A shows a significant improvement for the five different domains, group B for two, and group C only for one domain. The visual analogue score as part of the QOL registration shows a significant increase for the three groups, however the improvement is minor with age, and between A (14.6) and C (9.1) this improvement is significantly different (p = 0.047). Conclusions: Elderly patients have the same improvement of their symptomatic status as younger patients. However despite this improvement they have less benefit from CABG regarding to their quality of life and physical activity.

Key Words: Myocardial revascularization • Physical activity • Quality of life • Angina


   1. Introduction
Top
 Abstract
 1. Introduction
2. Patients and methods
 3. Results
 4. Discussion
 5. Conclusion
 Appendix A
 References
 
Improvements in survival and quality of life are the primary indications for coronary artery bypass grafting (CABG), and factors associated with survival post-CABG have been defined [1,2]. Several models for risk stratification are described for mortality as for morbidity [3,4]; however only limited data are available to identify patients who improve or even patients who worsen their overall quality of life (QOL) or physical activity (PA) post-CABG. Certainly in the group of elderly patients, this is an important question. Their functional reserve capacity is limited, they have more comorbidity and their life expectancy is of course limited by age [5,6].

In a previous report we studied gender and PA, and concluded that the increase in PA is similar in both gender [7]. A point of criticism was that women were significantly older; in this study we analyze the same patient cohort for overall QOL, PA, and symptomatic status (NYHA) 1-year post-CABG, with special interest for elderly patients.


   2. Patients and methods
Top
 Abstract
 1. Introduction
 2. Patients and methods
3. Results
 4. Discussion
 5. Conclusion
 Appendix A
 References
 
2.1 Patients
With the aid of our database, Coronary Surgery Database Radboud Hospital (CORRAD), we identified 568 patients with stable angina (NYHA <4) undergoing a primary isolated myocardial revascularization between January 2002 and December 2004, of which pre- and one-year follow-up registration of QOL using the EuroQoL questionnaire, and physical activity, was complete [8,9]. The EuroSCORE was used for risk stratification [3]

On the basis of their age the total group was classified in three groups. Group A, age less than 65 years: 285 patients (50.2%), group B, with an age of 65 but younger than 75 years: 210 patients (37%) and group C, older than 74 years: 73 patients (12.9%).

Appendix A presents the studied pre-, peri- and postoperative variables and their definitions.

2.2 Physical activity and QOL
For the evaluation of QOL, the instrument was used. The EuroQoL instrument is a standardized non-disease-specific instrument for describing and valuing health-related quality of life. For the purpose of data collection the EuroQoL instrument consists of two elements. The first element is a description of the respondent's own health by means of the EuroQoL classification. The respondent is required to rate his/her own health by checking three levels of severity; ‘no problems (coded as 1), some or moderate problems (coded as 2) and severe problems or unable (coded as 3)’, in each of five dimensions. These dimensions are: mobility, self-care, usual activities, pain/discomfort and anxiety/depression. Physical function is encompassed in the mobility and self-care dimensions, social function in the usual activities dimension and mental functioning can be assessed in the anxiety/depression dimension. The second element is a rating of the respondent's own current health by means of a visual analogue scale (VAS). The patient marks his own current health state on a kind of thermometer, ranging from zero (‘worst imaginable health state’) to 100 (‘best imaginable health state’).

For assessing specific PA the criteria of The Corpus Christi Heart Project are used [8]. The five activity levels and their description are presented in Appendix A. The five levels are coded from 1, the worst, to 5, the best.

2.3 Surgical technique
Five hundred and forty-four patients (95.8%) were operated using standard cardiopulmonary bypass technique, aortic and right atrial (two stage) cannulation, hypothermia (28–32 °C) and myocardial protection using St. Thomas’ Hospital cardioplegia. Twenty-four patients (4.2%) were operated off-pump without using cardiopulmonary bypass. Because this is only a small amount of patients we did not include off-pump as a variable in this study. For the patients operated with cardiopulmonary bypass, the mean time on the extra-corporal circulation (ECC-time) was 88.6 ± 33.0 min (range 22–359) and the mean duration of aortic cross-clamping (AoX-time) was 49 min (range 11–154). For the total group, there was a mean of 1.9 ± 0.3 grafts (range 1–3) and a mean of 3.2 ± 1.0 (range 1–7) distal anastomoses. Of all patients, 544 patients (94.2%) received at least one arterial graft.

2.4 Follow-up
The data result from our yearly-organized follow-up which is a written survey directly to the patients. This follow-up is approved by the local ethical and research council and participation in this follow-up is on a voluntary basis [10].

2.5 Statistical analysis
Characteristics of patients are presented as percentage for dichotome variables, and as mean ± standard deviation, and range for numerical variables. Differences in percentages were tested with the chi-square test, and numerical variables were tested with the F-test (one way analysis of variance). Paired Student's t-tests were performed to examine the mean differences in QOL and PA between the groups. Statistical significance was assumed at p ≤ 0.05.


   3. Results
Top
 Abstract
 1. Introduction
 2. Patients and methods
 3. Results
4. Discussion
 5. Conclusion
 Appendix A
 References
 
3.1 Patient population
Between January 2002 and December 2004, 1104 myocardial revascularizations were performed. Based on our clinical inclusion criteria, primary isolated and NYHA <4, 861 patients were available for this study. This group had a mean EuroSCORE risk of 2.6 ± 2.1 (0–11) and a hospital mortality of 1.7% (95% CI 0.8–2.6) (15/861 patients). The mean EuroSCORE risk of the deceased patients was 6.1 ± 2.3 (2–11). Of 744 patients (86%) there was preoperative QOL information available. During the 1-year follow-up 8 patients died and 10 patients were lost for follow-up or refused follow-up. Of the remaining 726 patients, 67 patients were excluded because of incomplete preoperative QOL information and 91 because of incomplete follow-up QOL information. So the study population consisted of a group of 568 patients, with a mean age of 64.3 ± 9.04 (31–85) years, a mean NYHA class of 2.8 ± 0.38 (1–3), and a mean EuroSCORE of 2.6 ± 2.04 (0–10). Patients excluded because of incomplete QOL information had a mean EuroSCORE of 2.6 ± 2.12 (0–9).

3.2 Preoperative data
Due to the split of our patients population in different age groups, there is a significant difference (p < 0.0005) in age between group A, B and C (Table 1 ). Analysis also shows a significant increase of the percentage of women with the increase in age (p < 0.0005). Furthermore there is no significant difference between the three groups concerning the registered comorbidity risk factors. Also the preoperative cardiac-related risk variables show no significant differences with the exception of the increase of the percentage of patients with a poor left ventricular function. From 1.4% in group A, 2.4% in group B and 5% in group C (p = 0.05). It is interesting that both the NYHA class partitioning and the average NYHA are not significantly different between the three groups.


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  		Table 1 Preoperative data
 
Table 2 presents the preoperative QOL and PA data. The PA registration shows a significant difference in the level classification with an high percentage of patients from group C in the two lower levels, but also a high percentage of patients in the three lowest levels in group A (p = 0.002). Also the mean PA level is significantly different between the three groups (p = 0.02). The mean PA level in group B is significant higher versus group A (p = 0.02) and versus group C (p = 0.012). Group A versus C is however not significantly different (p = 0.12).


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  		Table 2 Preoperative QOL and PA data
 
There is no significant difference in the registered VAS between the three groups. Concerning the five fields of the EuroQoL registration, there is only a significant difference for anxiety/depression, where younger patients indicate significant more problems with anxiety/depression than the elderly (p = 0.02).

3.3 Perioperative data
The perioperative data show no significant differences for different age groups except for the number of distal anastomoses and the use of arterial grafts. The number of distal anastomoses is significantly higher (p = 0.016) in group C (3.4 ± 3.8) than in group A (3.1 ± 3.3) and group B (3.1 ± 3.4) (p = 0.016). The percentage of patients that received at least one artificial graft was lower in group C (p < 0.0005) (Table 3 ).


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  		Table 3 Perioperative data
 
3.4 Postoperative data and follow-up variables
No statistical differences were found in the postoperative registered variables between the different groups except for the neurological (p = 0.014) and gastrointestinal (p = 0.009) complications. The percentage of patients with postoperative neurological complications was higher in group C (5.5%) than in group A (0.7%) and group B (1.4%), gastrointestinal complications were found more frequently in patients of group C (5.5%) than in group A (2.9%) and B (0.4%). Also pulmonary complications were seen more in group C (9.6%) than in group A (4.9%) and B (2.9%); however, this difference did not reach significance (p = 0.065) (Table 4 ).


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  		Table 4 Postoperative hospital data
 
Patients of group C stayed longer in the intensive care and also their total hospital stay was longer than patients of group A and B although this difference was not significant (Table 4).

Table 5 shows our 1-year follow-up data on NYHA, QOL and PA for the total group. There is a statistical significant decrease of the average NYHA class, from 2.8 ± 0.3 to 1.5 ± 0.79 (p < 0.0005). The VAS increased significantly from 62.9 ± 18.6 to 75.9 ± 17.6 (p < 0.0005), and also for the five different QOL domains there is a significant improvement. The average PA of the total group increased significantly from 2.7 to 3.1 (p < 0.0005).


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  		Table 5 Follow-up data for the total group
 
This overall improvement in NYHA, QOL and PA is however different in the three subgroups (Table 6 ). In group A the significant improvement is general: NYHA, VAS and the five domains of the QOL and the PA. For Group B, there is a significant improvement of NYHA, VAS and PA as in group A, but the increase of VAS and PA is less than in group A. The mean change in VAS is not significantly different, but the mean change in PA in group B is significantly less than in group A (p = 0.02) (0.21 vs 0.50). For the different domains of the QOL registration, there is only a significant improvement for daily activities and pain. The items mobility, self-care and anxiety/depression did not score significantly different one-year postoperatively in group B.


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  		Table 6 Follow-up data for the different age groups
 
This trend continues in group C. Besides the significant decrease in NYHA, the increase of the VAS is the only significant variable (p < 0.0005), but again less than in group A and B. For the different QOL domains, only the item daily activities reached significance (p = 0.05) the four others did not. Also in addition the increase in PA was not significant (p = 0.744).


   4. Discussion
Top
 Abstract
 1. Introduction
 2. Patients and methods
 3. Results
 4. Discussion
5. Conclusion
 Appendix A
 References
 
This study evaluated the impact of CABG on symptoms (NYHA), QOL and PA at one year after CABG, with special interest in the older patients. In our study, we compare three age groups, 75 years was the cut-off age for our oldest group, so 12.9% of the patients were included in this oldest group.

4.1 Patient characteristics
Only patients with NYHA III or lesser were included. In these patients the decision to operate can be taken in consideration and eventually patients’ expectations concerning postoperative QOL and PA discussed. This in contrast to patients in NYHA = 4, whose operation indication is angina not responding to therapy and these patients have a greater chance to improve their PA and QOL due to an improvement of their NYHA class.

The total group of patients was divided into three age groups A, B and C. Between these three groups there was a significant increase in the percentage of women. It is known that women tend to be older than men at the time of operation [11]. The other studied preoperative risk factors show no statistical difference between the three groups.

There was no difference in the percentage of preoperative myocardial infarction, 3-vessel disease, and left main stenosis. The incidence of patients with a poor left ventricular function reached a significant difference between the three groups (p = 0.05); however the number of patients (13/568) is so limited that no conclusion can be made.

The average angina class and the distribution of the classes were similar for the three groups. There was no significant difference for the VAS registration: however, a mean value of about 60 shows firstly and especially that the patients are not satisfied with their health state, but also that independent of age they all have the same evaluation of their health state, about 60% of what they expect of the best. For the five different fields of the EuroQoL registration there was no significant difference between the groups with the exception of a significant decrease of anxiety/depression from group A to C. The confrontation of young people with angina, cardiac problems and cardiac surgery has a larger mental by-effect on this younger group [12].

Physical activity shows a significant difference as well for the average PA as for the PA distribution. Older patients have a lower exercise capacity than younger, and also women have greater physical limitation related to stable anginal pain [13,14]. It is striking however that group A has a significant lower PA than group B. Probably their mental attitude plays a role, or these young patients are more than the others (group B and C), advised preoperatively not to do larger efforts.

4.2 Peri- and postoperative data
There is a statistical significantly lesser use of an arterial graft in group C. The importance of an arterial graft is situated in the long-term event-free survival. Striking is the significant higher number of distal anastomoses in group C and this is despite the fact that the incidence of patients with three vessel disease was not different between the groups. A possible explanation is that, indeed unconscious, there are fewer patients with diffuse atherosclerosis resulting in more distal anastomoses. However a clear explanation for this higher number of distal anastomoses is not found.

The postoperative in-hospital morbidity is summarized in Table 5. It is well known that older patients have more postoperative morbidity; certainly neurological and pulmonary but also gastrointestinal [5,6]. IC stay and hospital stay is increasing with age; however the differences did not reach significance in the studied group. Probably because in this group only hospital survivors are included.

4.3 Follow-up data
For the total group there is a significant improvement for NYHA, PA, the VAS and the different domains of the EuroQoL registration (Table 6), which shows again the good results of CABG [1,2,15,16]. The excellent results of CABG on angina are reflected by the significant decrease of the mean NYHA class in the three groups [1,2], with an equal mean change.

For physical activity there is a statistical significant improvement for groups A and B, but the improvement is lesser in group B (mean change 0.2 vs 0.5 in group A). The improvement in PA in group C does not result in a significantly higher follow-up PA (p = 0.744).

The impact of age on physical activity is well known [5,12,16]. There are also significantly more women in group C [17,18]; however based on our previous report and an additional analysis comparing the increase of PA of both gender in group C (data not shown) we doubt the influence of gender on the lesser improvement of PA in the oldest group [7].

For the different domains of the EuroQoL registration, there is a significant improvement for the five domains in group A. In group B, there is only a significant improvement for the domains daily activities and pain. The improvement for the other domains is not significant, and in group C only the domain daily activities reaches statistical significance (p = 0.05). This seems to be consistent with Jarvinen who concluded that patients aged more than 75 are likely to derive less benefit from CABG in terms of certain aspects of quality of life [13]. Besides the impact of age there are also significantly more women in group C probably resulting in less improvement in several fields of EuroQoL. Women are at risk of subjective cognitive difficulties, increased anxiety, decreased ability to perform tasks for daily living (IADL) and diminished work related activities (SF 36) [19,20]. Another explanation for the lesser improvement in QOL is the significantly higher number of patients with postoperative neural complications in group C. A decrease in postoperative cognitive functioning is associated with diminished health-related QOL [21].

That only in group A the domain anxiety/depression improved significantly confirms the idea that this anxiety/depression is related to the mental impact of the cardiac disease and operation in younger patients. This seems to be consistent with Rymaszewska et al. [22] and Vingerhoets [23] who stated that the drop in anxiety levels after surgery is more prominent in patients with high preoperative anxiety level patients.

That ‘pain’ is not significantly improving in the older group is probably due to the lower preoperative pain-registration in this older group. Kari reported that older patients report less bodily pain than younger [24]. Interesting is the persistent high score for postoperative pain, certainly for group A and B. We did not differentiate this pain in postoperative wound pain or recurrent angina or a simple sensation. However it is known that a lot of patients suffer from chronic post-CABG pain, and that higher age is a ‘protective’ factor regarding chronic post-surgery pain [25].

Also striking is that with age, first the domains mobility and then self-care, respond less. Two domains where physical activity is needed, that is corresponding with the minor improvement of PA with age. But we must realize that with age also a lot of non-cardiac reasons, vascular pathology, arthritis, pulmonary problems, reduce patients’ mobility.

Looking at the VAS registration, we see that there is a statistically significant higher VAS registration for the three groups. However, the improvement is lesser with age (group C is significantly less than group A). This VAS registration gives an impression of patients’ own evaluation of his health state. The fact that there is a good effect of CABG on angina and there is an improvement of PA for the oldest group, is however not significant, but there is a significant improvement of the possibility to perform daily activities suggesting that these variables especially result in a higher VAS registration.

4.4 Limitations of the study
A point criticism in the methodology of our study is the conversion of physical activity, and the different domains of the EuroQoL and for the NYHA classification into a metric scale. This is however common in this kind of investigation.

Probably it would be more appropriate to use the Canadian Cardiovascular Society Classification for angina than the NYHA score. The use of the EuroQoL instrument and not the SF 16-score [20] is also a point of criticism; however our personal experience is that certainly in follow-up the EuroQoL has a higher and more complete response.

Other limitations are: the small number of patients, certainly in the older group and the limited follow-up (one year). Our patient selection means that only elective, stable patients are included. So our results cannot be generalized for the total population of patients undergoing myocardial revascularization. The suspicion that particularly low-risk patients complete the QOL information is inconsistent with the same EuroSCORE risk of this group of patients who were not included.

Another point is that we make no difference between PA limitation due to cardiac and peripheral vascular pathology, certainly in the older group. Also the information about cardiac rehabilitation programs is limited; 85% of the patients followed a rehabilitation program; however we were not informed about the level of these programs or the results [7]. We did not focus on psychosocial problems such as lack of companion and motivation or lack of mental energy and vitality. And lastly we do not include ‘event’ information that may eventually influence the PA or QOL, at one-year follow-up.


   5. Conclusion
Top
 Abstract
 1. Introduction
 2. Patients and methods
 3. Results
 4. Discussion
 5. Conclusion
Appendix A
 References
 
CABG is beneficial for relief of angina and improves QOL and the PA level. The improvements in VAS and PA are significantly lower with age. However the VAS improvement is still significant for the oldest patients. The relief of angina is constant with age. In the oldest patient group only the daily activities domain of the EuroQoL reaches significant improvement. The clinical implication is that based on the low improvement in EuroQoL and PA the decision to perform CABG on older patients should be reconsidered and related to the operative risk. However the improvement in VAS and the patient's perception of health status improvement is still significant for older patients and should also be taken into account.


   Appendix A
Top
 Abstract
 1. Introduction
 2. Patients and methods
 3. Results
 4. Discussion
 5. Conclusion
 Appendix A
References
 
Variables and definitions


Variable
 Definition
Age (years) Years
BMI Body mass index
Diabetes Diet-controlled, oral therapy or insulin dependent diabetes
Hypertension Systolic blood pressure > 160 mmHg, or diastolic pressure > 100 mmHg. Or antihypertensive medication.
Hyperlipidemia Total cholesterol > 250 mg/dl or triglyceride level 200 mg/dl
Vascular disease Peripheral, abdominal vascular pathology or operation
Neurological disease Cerebrovascular accidents and/or transient ischemic attack
Renal disease Renal failure (creatinine ≥1.7 mg/dl [150 µmol/l]) preoperative dialysis, renal transplantation
Pulmonary disease Chronic obstructive pulmonary disease and/or history of previous lung disease
Gastrointestinal disease Gastro-duodenal, colon, disease/operation
Preoperative myocardial infarction (Pre-MI) History of myocardial infarction before the operation
Main stem stenosis Left main stenosis >70%
Left Ventricular function Ejection fraction: good (≥30%) bad (<30%)
ECC Extra corporal circulation, duration in minutes
AoX Aortic cross clamp, duration in minutes
Perioperative myocardial infarction (peri-MI) By finding of at least two of the four following criteria: (1) prolonged typical chest pain not responding on rest or nitrates, (2) enzyme level elevation (CK = MB, CK, troponin), (3) new wall motion abnormalities, (4) ECG (at least two showing new Q-wave or ST-T changes
Wound complications Sternal dehiscence with refixation, mediastinitis
Stroke Postoperative cerebrovascular accidents and/or transient ischemic attack
Renal complications Postoperative renal failure (creatinine ≥1.7 mg/dl [150 µmol/l]), dialysis
Pulmonary complications Postoperative pulmonary infection
Gastrointestinal complications Postoperative gastrointestinal complications
Visual analogue score (VAS) Quality of life score–EuroQoL

Activity levels and description
Level
 Activity description
 Activity examples
Sedentary Essential no PA above minimum demands of daily living Watching TV, working at desk, riding car
Minimally Activity during normal daily routine, 15–30 min/day, very light to fairly light exertion Some stair-climbing, light gardening, light housekeeping, light home repairs
Mildly Activity to exercise muscle groups, 15–30 min/day, fairly light to somewhat hard exertion Calisthenics, lifting weights, heavy gardening, heavy housekeeping
Moderately ≥1 dynamic activities performed 1–3 times/week, 15 min/session, marked increase in heart rate or some what hard exertion Running, jogging, bicycling, fast walking, dancing, tennis
Vigorously ≥ 1 dynamic activities performed 3 times/week, 20 min/session, somewhat hard to hard exertion Vigorous calisthenics, aerobic dancing, aerobic workouts, competition sport


   References
Top
 Abstract
 1. Introduction
 2. Patients and methods
 3. Results
 4. Discussion
 5. Conclusion
 Appendix A
 References
 

  1. Eagle KA, Guyton RA, Davidoff R, Ewy GA, Fonger J, Gardner TJ, Gott JP, Herrmann HC, Marlow RA, Nugent WC, O’Connor GT, Orszulak TA, Rieselbach RE, Winters WL, Yusuf W, Gibbons RJ, Alpert JS, Garson Jr. A, Gregoratos G, Russell RO, Smith Jr. SC. ACC/AHA guidelines for coronary artery bypass graft surgery: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines. J Am Coll Cardiol 1999;34:1262-1346.[Free Full Text]
  2. Eagle KA, Guyton RA, Davidoff R, Edwards FH, Ewy GA, Gardner TJ, Hart JC, Herrmann HC, Hillis LD, Hutter AM, Lytle BW, Marlow RA, Nugent WC, Orszulak TA. ACC/AHA 2004 Guideline update for coronary artery bypass surgery. Circulation 2004;110:e340-e437.[Free Full Text]
  3. Nashef SAM, Roques F, Michel P, Gauducheau E, Lemeshow S, Salamon R, the EuroSCORE study group European system for cardiac preoperative risk evaluation (EuroSCORE). Eur J Cardiothorac Surg 1999;16:9-13.[Abstract/Free Full Text]
  4. Kurki TSO, Katja M. Preoperative prediction of postoperative morbidity in coronary artery bypass grafting. Ann Thorac Surg 1996;61:1740-1745.[Abstract/Free Full Text]
  5. Glower DD, Christopher TD, Milano CA, White WD, Smith LR, Jones RH, Sabiston Jr. DC. Performance status and outcome after coronary artery bypass grafting in persons aged 80–93 years. Am J Cardiol 1992;70:567-571.[CrossRef][Medline]
  6. Cloin ECW, Noyez L. Changing profile of elderly patients undergoing coronary bypass surgery. Neth Heart J 2005;13:132-138.
  7. Markou ALP, Evers M, Swieten van HA, Noyez L. Gender and physical activity one year after myocardial revascularization for stable angina. ICVTS 2008;7:96-101.
  8. Steffen-Batey L, Nichaman MZ, Goff DC, Frankowski RF, Hanis CL, Ramsey DJ, Labarthe DR. Change in level of physical activity and risk of all-cause mortality or reinfarction. The Corpus Christi Heart Project. Circulation 2000;102:2204-2209.[Abstract/Free Full Text]
  9. Brooks R, EuroQoL Group EuroQoL: the current state of play. Health Policy 1996;37:53-72.[CrossRef][Medline]
  10. Wouters CW, Noyez L. Is no news good news? Organized follow-up, an absolute necessity for the evaluation of myocardial revascularization. Eur J Cardiothorac Surg 2004;26:667-670.[Abstract/Free Full Text]
  11. Mikhail GW. Coronary revascularization in women. Heart 2006;92:iii19-iii23.[Abstract/Free Full Text]
  12. Koivula M, Paunonen-Ilmonen M, Tarkka MT, Tarkka M, Laippala P. Fear and anxiety in patients awaiting coronary artery bypass grafting. Heart Lung 2001;30:302-311.[CrossRef][Medline]
  13. Järvinen O, Saarinen T, Julkunen J, Huhtala H, Tarkka MR. Changes in health-related quality of life and functional capacity following coronary artery bypass graft surgery. Eur J Cardiothorac Surg 2003;24:750-756.[Abstract/Free Full Text]
  14. Kimble LP, McGuire DB, Dunbar SB, Fazio S, De A, Weintraub WS, Strickland OS. Gender differences in pain characteristics of chronic stable angina and perceived physical limitation in patients with coronary artery disease. Pain 2003;101:45-53.[CrossRef][Medline]
  15. Herlitz J, Wiklund I, Sjoèland H, Karlson BW, Karlsson T, Haglid M, Hartford M, Caidahl K. Relief of symptoms and improvement of quality of life five years after coronary artery bypass grafting in relation to preoperative ejection fraction. Qual Life Res 2000;9:467-476.[CrossRef][Medline]
  16. Rumsfeld JS, Ho PM, Magid DJ, McCarthy Jr. M, Shroyer ALW, MaWhinney S, Grover FL, Hammermeister KE. Predictors of health-related quality of life after coronary artery bypass surgery. Ann Thorac Surg 2004;77:1508-1513.[Abstract/Free Full Text]
  17. Vaccarino V, Lin ZQ, Kasl SV, Mattera JA, Roumanis SA, Abramson JL, Krumholz HM. Gender differences in recovery after coronary artery bypass surgery. J Am Coll Cardiol 2003;41:307-314.[Abstract/Free Full Text]
  18. Sjoland H, Wiklund I, Caidahl K, Hartford M, Karlsson T, Herlitz J. Improvement in quality of life differs between women and men after coronary artery bypass surgery. J Intern Med. 1999;245(5):445-454.[CrossRef][Medline]
  19. Butte PB, Blumenthal MJ, Welsh-Bohmer K, White WD, Mark D, Landolfo K, Newman ME. Female gender is associated with impaired quality of life 1 year after coronary artery bypass surgery. Psychosom Med 2003;65(6):944-951.[Abstract/Free Full Text]
  20. Lindquist R, Dupuis G, Terrin ML, Hoogwerf B, Czajkowski, Herd JA, Barton FB, Tracy MF, Hunninghake DB, Treat-Jacobson D, Shumaker S, Zyzanski S, Goldenberg I, Knatterud GL, POST CABG Biobehavioral Study Investigators Comparison of health-related quality-of-life outcomes of men and women after coronary artery bypass surgery through 1 year: findings from the post-CABG Biobehavioral Study. Am Heart J 2003;146:1038-1044.[CrossRef][Medline]
  21. Newman MF, Grocott HP, Mathew JP, White WD, Landolfo K, Reves JG, Laskowitz DT, Mark DB, Blumenthal JA, Swearer JA. Report of the substudy assessing the impact of neurocognitive function on quality of life 5 years after cardiac surgery. Stroke 2001;32:2874-2881.[Abstract/Free Full Text]
  22. Rymaszewska J, Kiejna A, Hadrys T. Depression and anxiety in coronary artery bypass grafting patients. Eur Psychiatry 2003;18:155-160.[CrossRef][Medline]
  23. Vingerhoets G. Perioperative anxiety and depression in open-heart surgery. Psychosomatics 1998;39:30-37.[Abstract/Free Full Text]
  24. Kari GH, Pål WA, Stian L, Roar S. Health-related quality of life three years after coronary surgery: a comparison with the general population. Scand Cardiovasc J 2006;40:29-36.[CrossRef][Medline]
  25. Eisenberg E, Pultorak Y, Pud D, Bar-El Y. prevalence and characteristics of post coronary artery bypass graft surgery pain (PCP). Pain 2001;92:11-17.[Medline]




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