Predictors of Quality of Life Improvement after 2 Years of Coronary Artery Bypass Surgery

Risk Prediction Models for Long-Term Survival after Cardiac Surgery: A Systematic Review

BACKGROUND

The reporting of alternative postoperative measures of quality after cardiac surgery is becoming increasingly important as in-hospital mortality rates continue to decline. This study aims to systematically review and assess risk models designed to predict long-term outcomes after cardiac surgery.

METHODS

The MEDLINE and Embase databases were searched for articles published between 1990 and 2020. Studies developing or validating risk prediction models for long-term outcomes after cardiac surgery were included. Data were extracted using checklists for critical appraisal and systematic review of prediction modeling studies.

RESULTS

Eleven studies were identified for inclusion in the review, of which nine studies described the development of long-term risk prediction models after cardiac surgery and two were external validation studies. A total of 70 predictors were included across the nine models. The most frequently used predictors were age (n = 9), peripheral vascular disease (n = 8), renal disease (n = 8), and pulmonary disease (n = 8). Despite all models demonstrating acceptable performance on internal validation, only two models underwent external validation, both of which performed poorly.

CONCLUSION

Nine risk prediction models predicting long-term mortality after cardiac surgery have been identified in this review. Statistical issues with model development, limited inclusion of outcomes beyond 5 years of follow-up, and a lack of external validation studies means that none of the models identified can be recommended for use in contemporary cardiac surgery. Further work is needed either to successfully externally validate existing models or to develop new models. Newly developed models should aim to use standardized long-term specific reproducible outcome measures.

The Quality of Life in Patients With Valve Prosthesis After Undergoing Surgery for Valvular Heart Diseases

Background and objective Surgery for valvular heart disease by valve replacement procedures has become one of the most frequently performed cardiac operations to improve the quality of life (QoL). Its long-term outcomes are assessed using the quality-of-life index (QLI). This study aimed to evaluate the QoL in patients who received valve prostheses after surgery for valvular heart diseases at King Abdulaziz University in Jeddah from 2010 to 2023. Methods This was a descriptive cross-sectional study of 59 patients aged 18 years or older who underwent surgical mitral and aortic valve replacement, involving either mechanical or tissue valves, from January 2010 to May 2023 They were selected using a non-probability convenient sampling technique. Their medical records were reviewed and the participants were interviewed via phone using the World Health Organization Quality of Life-BREF (WHOQOL-BREF) questionnaire, which was used to measure the QoL of patients (https://neurotoolkit.com/whoqol-bref/). Results The study found that the QoL of the participants varied across different domains. The psychological domain had the highest mean score of 79.76, while the physical domain had the lowest mean score of 61.5. The other domains, - social, environmental, and spiritual - had mean scores of 68.05, 69.9, and 73.25, respectively. There was a statistically significant association between the QoL and nationality and chronic diseases. However, the duration after surgery and the type of valve did not significantly correlate with the QoL in the different domains. Conclusion Based on our findings, heart valve replacement improves the QoL of patients. Healthcare organizations and providers should aim to improve the management of chronic diseases to optimize outcomes.

The impact of socio-demographic factors on health-related quality of life after coronary artery bypass surgery

OBJECTIVES

To achieve a beneficial impact on long-term outcome after coronary artery bypass grafting (CABG), the goal of the present study was the early identification of patients at risk of impaired postoperative health-related quality of life (HRQoL), particularly evaluating the significance of socio-demographic variables.

METHODS

In this prospective, single-centre cohort study of patients having an isolated CABG (January 2004-December 2014), preoperative socio-demographic (preSOC) and preoperative medical variables as well as 6-month follow-up data including the Nottingham Health Profile were analysed in 3,237 patients.

RESULTS

All preSOC (gender, age, marriage and employment) and follow-up (chest pain, dyspnoea) variables proved to have significant influence on HRQoL (P < 0.001), male patients below 60 years being particularly impaired. The effects of marriage and employment on HRQoL are modulated by age and gender. The significance of the predictors of reduced HRQoL differs between the 6 Nottingham Health Profile domains. Multivariable regression analyses revealed explained proportions of variance amounting to 7% for preSOC and 4% for preoperative medical variables.

CONCLUSIONS

The identification of patients at risk of impaired postoperative HRQoL is decisive for providing additional support. This study reveals that the assessment of 4 preoperative socio-demographic characteristics (age, gender, marriage, employment) is more predictive of HRQoL after CABG than are multiple medical variables.

Depressive symptoms, perceived control and quality of life among patients undergoing coronary artery bypass graft: a prospective cohort study

BACKGROUND

Coronary artery bypass graft surgery (CABG) is an intervention directed toward improving the Quality of Life (QoL) for patients with coronary artery disease. Depression can affect QoL negatively among this population. Perceived control (PC) decreased the effect of anxiety on QoL, however, this effect has not been well-studies regarding depression. Therefore, the purpose of this study was to check the effect of depression on QoL among CABG patients and to determine if preoperative PC moderates this effect.

METHODS

This was a prospective observational cohort study conducted on a consecutive sample of 200 patients from three hospitals in Amman, Jordan. Depression Anxiety and Stress Scale, Short-Form Health Survey-36, and Arabic version of the Control Attitude Scale-Revised were used to measure depressive symptoms, QoL and PC respectively. Data were analyzed using t test and step wise multiple regression followed by simple slope analysis.

RESULTS

Postoperative Physical Component Summary (PCS) was better than preoperative PCS (mean ± SD: 38.2 ± 9.4 vs. 36.6 ± 9.5, P < 0.001). Postoperative Mental Component Summary (MCS) was better than preoperative MCS (mean ± SD: 44.3 ± 11.5 vs. 41.4 ± 11.4, P < 0.001). Preoperative depression was higher than postoperative depression; (mean ± SD: 12.8 ± 6.8 vs.11.1 ± 6.7, P < 0.01). Simple slope analysis was significant (simple slope = 0.41, t = 6.1, P < 0.001), indicating the moderating effect of PC.

CONCLUSION

Patients undergoing CABG surgery had poor QoL and high levels of depression. Perceived control moderated this relationship and improve QoL. Assessing depression levels and implantation of interventions to enhance perceived control levels prior to operation might improve QoL.

Diagnostic accuracy and suitability of instruments that screen for obstructive sleep apnoea, insomnia and sleep quality in cardiac patients: a meta-analysis

BACKGROUND

A number of clinical guidelines recommend that all cardiac rehabilitation patients should be screened for potential sleep disorders with a validated screening instrument. There is currently no consensus on what specific tools should be used.

OBJECTIVE

To identify tools that are practical to use in the clinical environment and have high diagnostic accuracy.

METHODS

We systematically searched online databases to identify patient reported outcome instruments that have been used in published research studies to assess the likelihood of obstructive sleep apnoea (OSA) in cardiac patients. In studies that provided diagnostic data, these data were extracted and verified via an evidence-based diagnostic calculator. Where sufficient numbers of studies were available, a meta-analysis was conducted to determine pooled estimates of specificity, sensitivity and diagnostic odds ratios. Selected papers were qualitatively assessed using the Standards for Reporting Diagnostic accuracy studies (STARD).

RESULTS

Of the 21 instruments identified, six detected likelihood of OSA, two assessed daytime sleepiness, five assessed insomnia and eight examined sleep quality. A meta-analysis of 14 studies that assessed diagnostic accuracy of moderate OSA, revealed moderate sensitivity for the Berlin Questionnaire, Sens = 0.49 (95% CI 0.45-0.52) and good sensitivity for the Stop-BANG, Sens = 0.93 (95% CI 0.87-0.96) but poor specificity at standard cut-off criteria.

CONCLUSION

There are promising practical tools available to screen patients with OSA and other sleep disorders in cardiac rehabilitation settings, but specificity could be improved. Additional assessment of sleep quality may enhance prognostic ability with both OSA and insomnia screening.

IL-8 and CRP moderate the effects of preoperative psychological interventions on postoperative long-term outcomes 6 months after CABG surgery - The randomized controlled PSY-HEART trial

INTRODUCTION

Inflammation has been related to several somatic and psychological disorders and may moderate effects of psychological interventions. In the PSY-HEART trial patients benefitted from preoperative psychological interventions before undergoing coronary artery bypass graft surgery (CABG) and, if necessary, concomitant valvular surgery, compared to standard medical care. In this study we examined whether patients' baseline inflammatory status moderated the intervention effects.

MATERIAL AND METHODS

In a prospective three-arm randomized clinical trial with 6-months follow-up, 124 patients scheduled for CABG surgery alone or concomitant with valvular surgery were randomized to (i) standard medical care only (SMC) or two preoperative psychological interventions: (ii) CBT-based optimizing expectations (EXPECT) and an (iii) an active control group focusing on emotional support (SUPPORT). Available baseline CRP- (n = 79), IL-6- (n = 78), IL-8- (n = 78) and TNF-alpha-(n = 80) parameters were considered as potential moderators (CRP as a categorical and continuous moderator). Linear mixed model analyses were calculated to test whether baseline inflammatory levels moderated intervention effects on disability, mental and physical quality of life at 6 months after surgery.

RESULTS

IL-8 moderated intervention effects on patients' disability and categorical CRP moderated intervention effects on mental quality of life. Follow-up tests indicated that EXPECT (and in part SUPPORT) led to lower postoperative disability and higher mental quality of life compared to SMC in patients with low baseline inflammatory markers. EXPECT indicated higher mental quality of life compared to SUPPORT in the high CRP subgroup. Patients in the SMC group had higher mental quality of life in the high CRP subgroup compared to the low CRP subgroup.

CONCLUSION

Especially for patients with a lower inflammatory baseline status preoperative psychological interventions might be helpful to optimize long-term CABG surgery outcomes.

Short-term outcomes of surgical myocardial revascularization on health-related quality of life: a validation of the Arabic MacNew heart disease questionnaire

Background

Impaired quality of life (QOL) is common in coronary heart disease and is the major indications for coronary artery bypass graft (CABG) operations. This study aims to compare the QOL of patients with coronary heart disease before and after CABG surgery.

Results

A translated Arabic version of the Mac-New health-related QOL questionnaire was used to evaluate QOL improvement in 446 patients who benefited from elective CABG at Nasser Institute for Research and Treatment. There was a statistically significant improvement in physical, emotional, social, and global domains of QOL, as evaluated 3 and 6 months after surgery. Follow-up was 90.4% complete. At 3 months, multiple linear regression has shown that male patients (β = 0.48, p ≤ 0.001) and rural residence (β = 0.39, p ≤ 0.001) were significant independent predictors of improvement in physical QOL domain. While hypercholesterolemia (β = −0.20, −0.49, −0.37, −0.46, p ≤ 0.001), hypertension (β = −0.29, −0.39, p ≤ 0.001, β = −0.35, −β = 0.35, p = 0.001), and smoking (β = −0.79, p ≤ 0.001, β = −0.33, p = 0.04, β = −0.69, p ≤ 0.001, β = −0.47, p = 0.005) were significant predictors of worsening in physical, emotional, social, and global domains, respectively. At 6 months, low preoperative ejection fraction (EF) ≤ 40% was the strongest predictor of improvement (β = 0.54, 0.49, 0.44, and 0.52, p ≤ 0.001) in physical, emotional, social, and global domains of QOL, respectively. But, peripheral vascular disease (PVD) (β = −0.53, p = 0.05, β = −0.81, p = 0.005, β = −0.62, p = 0.03, β = −0.76, p = 0.008) and smoking (β = −0.53, p = 0.001, β = −0.42, p = 0.01, β = −0.42, p = 0.01, β = −0.41, p = 0.02) were significant predictors of worsening in physical, emotional, social, and global domains of QOL, respectively.

Conclusions

CABG surgery improved in all domains of QOL. Further studies are required to evaluate changes in QOL at longer period intervals.

Determinants of non-recovery in physical health-related quality of life one year after cardiac surgery: a prospective single Centre observational study

BACKGROUND

Recent studies show that substantial percentage of patients experienced worsening of health related quality of life (HRQoL) 1 year after cardiac surgery. The aim of this study is to identify risk factors that interfere with improvement of HRQoL.

METHODS

From December 2015 till July 2017 a prospective single centre observational study was carried out in 1920 patients participated who underwent non-salvage cardiac surgery. All patients were requested to complete a Short Form 36 (SF-36) questionnaire before and 1 year after surgery. Primary aim of the study was to identify risk factors for non-recovery in the physical domain of the SF-36 in all cardiac surgery patients. Secondary aim was to identify identical risk factors in patients with isolated coronary artery bypass grafting.

RESULTS

After cardiac surgery, the questionnaires for physical and mental health were completed by respectively 803 and 807 patients. Median age was 69[62-75] years, and 77% was male. In comparison to the preoperative status, 176 patients (21.9%) did not display an improvement in the SF-36 physical domain score 1 year after cardiac surgery. In a multivariate analysis independent risk factors for non-recovery in the SF-36 physical domain were baseline SF36 physical domain score (OR 0.954[0.942-0.965], P < 0.001), diabetes (OR 0.437 [0.265-0.720], P 0.001), female sex (OR 0.492 [0.307-0.789], P 0.003), post-operative infection (OR 0.240 [0.109-0.525], P < 0.001) and PCI within 1 year (OR 0.113 [0.036-0.349], P < 0.001) For isolated CABG, 23.2% of patients did not display an improvement in the physical domain score and risk factors appeared to be identical.

CONCLUSIONS

Twenty two percent of all cardiac surgery patients did not show an improvement in the physical domain score of the HRQoL between the preoperative period and 1 year after surgery. Independent risk factors for non-recovery after cardiac surgery were baseline SF-36 physical domain score, diabetes, female sex, any postoperative infection and the need for PCI in the first year. Further research is needed to tailor the patient selection procedure prior to surgery and potentially modify risk factors in the perioperative process.

TRIAL REGISTRATION

Due to type of study not applicable. https://www.ccmo.nl/metcs/erkende-metcs/regionale-toetsingscommissie-patientgebonden-onderzoek .

Quality of life 10 years after cardiac surgery in adults: a long-term follow-up study

Background

Quality of life (QoL) is a multifactorial concept that assesses physical and mental health. We prospectively studied the quality of life of patients undergoing coronary artery bypass graft (CABG) surgery using the Short-Form 36-item questionnaire (SF-36) up to 10 years after surgery.

Methods

Between January 2000 and December 2002, all patients undergoing elective isolated CABG in the cardiac & thoracic surgery department of a large university hospital in Eastern France underwent initial QoL evaluation with the SF-36. The same questionnaire was mailed to every patient annually (± 2 weeks around the date of surgery) up to 10 years after their operation. We recorded socio-demographic and clinical variables at inclusion. Predictors of impaired QoL at 10 years were identified by logistic regression.

Results

A total of 272 patients (213 men, 59 women) were enrolled; mean age at inclusion was 65 ± 10 years. At 10 years post-surgery, 81 patients had died (29.7%). The physical component summary (PCS) score was significantly higher at 5 years after surgery than at baseline (p < 0.01), and significantly lower at 10 years than at 5 years (p < 0.01), although there remained a significant difference between 10-year PCS and baseline score (p = 0.004). The mental component summary (MCS) score was significantly higher at 5 years than at the time of surgery (p < 0.001), and remained significantly higher compared to baseline at 10 years after surgery (p = 0.010). By multivariate analysis, diabetes and dypsnea were both associated with worse PCS at 10 years, while lower age was associated with better 10-year PCS. Only diabetes was associated with impaired MCS at 10 years.

Conclusions

Cardiac surgery appears to durably and positively affect both physical and mental components of quality of life.

Electronic supplementary material

The online version of this article (10.1186/s12955-019-1160-7) contains supplementary material, which is available to authorized users.

Comparisons and correlations of pain intensity and respiratory and peripheral muscle strength in the pre- and postoperative periods of cardiac surgery

OBJECTIVE

To evaluate respiratory and peripheral muscle strength after cardiac surgery. Additionally, we compared the changes in these variables on the third and sixth postoperative days.

METHODS

Forty-six patients were recruited, including 17 women and 29 men, with a mean age of 60.50 years (SD = 9.20). Myocardial revascularization surgery was performed in 36 patients, replacement of the aortic valve in 5 patients, and replacement of the mitral valve in 5 patients.

RESULTS

A significant reduction in respiratory and peripheral muscle strength and a significant increase in pain intensity were observed on the third and sixth postoperative days (p < 0.05), except for the variable maximal inspiratory pressure; on the sixth postoperative day, maximal inspiratory pressure values were already similar to the preoperative and predicted values (p > 0.05). There was an association between peripheral muscle strength, specifically between maximal expiratory pressure preoperatively (rs = 0.383; p = 0.009), on the third postoperative day (rs = 0.468; p = 0.001) and on the sixth postoperative day (rs = 0.311; p = 0.037). The effect sizes were consistently moderate-to-large for respiratory muscle strength, the Medical Research Council scale and the visual analog scale, in particular between preoperative assessment and the sixth postoperative day.

CONCLUSION

There is a decrease in respiratory and peripheral muscle strength after cardiac surgery. In addition, maximal expiratory pressure is the variable that is most associated with peripheral muscle strength. These variables, especially respiratory and peripheral muscle strength, should be considered by professionals working in the intensive care setting.

Suicidal ideation in patients with coronary heart disease and hypertension: Baseline results from the DEPSCREEN-INFO clinical trial

BACKGROUND

A high proportion of cardiac patients suffers from depression, which is an antecedent for suicidal ideation. This study identifies clinical vulnerabilities for suicidal ideation in cardiac patients.

METHODS

The primary outcome of the study was severity of suicidal ideation as measured with the Patient Health Questionnaire (PHQ-9) item No. 9. Covariates were demographics, cardiac characteristics (i.e., Canadian Cardiovascular Society angina rating of chest pain and New York Heart Association rating of shortness of breath), depression (PHQ-8,i.e., PHQ-9 minus item No. 9), anxiety (Generalized Anxiety Disorder-7, GAD-7), somatic symptoms (PHQ-15), illness perception (Brief-Illness Perception Questionnaire), and health-related quality of life (EuroQol-5D, EQ 5D).

RESULTS

Data from 1,976 patients were analysed. At least 14% (95% CI [12%, 16%]) of patients indicated suicidal ideations within the last 2 weeks. Bivariate analyses yielded associations between suicidal ideation and higher levels of depression severity, anxiety severity, somatic symptom burden, chest pain, shortness of breath, negative illness perceptions, reduced health-related quality of life, and a higher probability of living alone (all p < 0.001). A multivariable ordinal regression revealed depression severity and anxiety severity to show the highest associations with suicidal ideation (OR_PHQ-8  = 1.22, p < 0.001; OR_GAD-7  = 1.09, p < 0.001). Having a defibrillator implant was associated with a lower probability of suicidal ideation (OR = 0.27, p = 0.017).

CONCLUSIONS

This study identified several clinical vulnerabilities of suicidal ideation. The results stress the importance of screening for suicidal ideation in clinical practice.