823821

research-article2019
HEJ0010.1177/0017896918823821Health Education JournalHately and Mandic

Original Article

Health Education Journal

Physical activity, physical function

1­–13
© The Author(s) 2019
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DOI: 10.1177/0017896918823821
https://doi.org/10.1177/0017896918823821
based maintenance cardiac journals.sagepub.com/home/hej

rehabilitation

Garrick Hately and Sandra Mandic

Active Living Laboratory, School of Physical Education, Sport and Exercise Science, University of Otago, Dunedin, New
Zealand

Abstract
Objective: This study compared physical activity (PA), physical function and quality of life in elderly
individuals with coronary artery disease (CAD) and their non-CAD peers participating in community-based,
maintenance cardiac rehabilitation (CR).
Design: Cross-sectional study.
Setting: Community-based maintenance CR programme.
Methods: A total of 39 individuals (71.8% women; age 70.5 ± 5.5 years; 13 CAD, 26 non-CAD) wore an
accelerometer for 7 days and completed anthropometry, chair stands, handgrip strength, a Short Physical
Performance Battery, a PA questionnaire (IPAQ- SF), a quality of life questionnaire (SF-36), a 10-m shuttle
walk test and two 6-minute walk tests.
Results: Compared with the non-CAD group, the CAD group accumulated more objectively measured
moderate-to-vigorous PA per week (329.7  ±  233.3 vs 160.6  ± 149.5 minutes, p = .013), achieved PA
guidelines on more days per week (3.8 ± 2.2 vs 2.1 ± 2.6 days/week, p = .042), had a lower proportion of
body fat (27.5 ± 8.4% vs 36.5 ± 8.7%, p = .004) and a higher proportion of muscle mass (72.5 ± 8.4% vs
63.0 ± 9.8%, p = .022). Physical function and quality of life were not different between the groups.
Conclusion: Elderly CAD patients participating in community-based maintenance CR performed more PA
and had more favourable body composition but similar physical function and quality of life compared with
their non-CAD peers. Long-term participation in community-based maintenance CR may promote PA in
elderly CAD patients and help maintain physical function and quality of life at a level similar to that of their
non-CAD peers. However, due to a small sample size, these findings should be interpreted with caution and
examined in future larger studies.

Keywords
Cardiac rehabilitation, coronary artery disease, elderly, physical activity, quality of life

Corresponding author:
Sandra Mandic, Active Living Laboratory, School of Physical Education, Sport and Exercise Science, University of Otago,
PO Box 56, Dunedin 9054, New Zealand.
Email: sandra.mandic@otago.ac.nz
2 Health Education Journal 00(0)

Introduction
Coronary artery disease (CAD) remains one of the leading causes of mortality worldwide ((World
Health Organisation (WHO), 2014). Exercise capacity is the strongest predictor of all-cause and
cardiovascular mortality in individuals with (Mandic et al., 2010) and without cardiovascular dis-
ease (Mandic et al., 2009). In older adults, exercise capacity also correlates with physical function
and the ability to perform activities of daily living (Morey et al., 1998). Following cardiac events
such as a heart attack or heart surgery, individuals are more likely to have low levels of physical
activity (PA) and lower exercise capacity compared with their non-CAD peers (Hansen et al.,
2010).
As few as 27% of CAD patients have been reported to regularly meet the current PA guidelines
of ⩾150 minutes of moderate-to-vigorous PA per week (Hansen et al., 2010). Recent evidence
suggests that participation in cardiac rehabilitation (CR) increases PA and improves multiple car-
diovascular risk factors (Mampuya, 2012). Participation in CR can also improve the psychologi-
cal well-being and quality of life in CAD patients (Seki et al., 2003). However, a considerable
number of eligible individuals do not participate in CR (Blackburn et al., 2000) or drop out of CR
within the first 6 months (Oldridge and Streiner, 1990). This lack of participation in CR is particu-
larly evident for elderly CAD patients, who have been subject to age bias in CR referral (Grace
et al., 2009) and are less likely to participate in CR compared with their younger counterparts
(Witt et al., 2004).
In addition, most outpatient CR programmes have a limited duration of 8–12 weeks without
further follow-on maintenance CR programmes available (Mandic et al., 2018). Only a few previ-
ous studies have investigated the effects of long-term, maintenance CR (duration >1 year) in eldely
CAD patients (Mandic et al., 2015; Mandic et al., 2018), despite initial evidence showing that
long-term participation in CR may promote exercise adherence and functional capacity among
elderly patients with CAD (Brubaker et al., 1996). However, it remains unknown how levels of PA,
physical function and quality of life in elderly CAD patients compare with their non-CAD peers.
The purpose of this cross-sectional study was to compare the PA habits, physical function and qual-
ity of life in elderly individuals with CAD and non-CAD who participated in community-based,
maintenance CR.

Materials and methods

Participants
Participants were recruited from two community-based, maintenance CR programmes, The Otago
Phoenix Club and the Taieri Fit and Fun group, in Dunedin, New Zealand between February and
October 2017. Recruitment of participants was conducted using presentations at CR clubs, as well
as advertisement in CR club newsletters and on their websites. Participants were classified as either
CAD (history of CAD defined as having a history of myocardial infarction, coronary angioplasty
or stent insertion, valve surgery or coronary artery bypass graft surgery) or non-CAD (no previous
history of CAD). Non-CAD participants served as a comparison group in this study. Inclusion
criteria for both CAD and non-CAD participants were age ⩾65 years and a current membership
within a CR club (membership defined as having participated in ⩾1 session within the previous
12 months). Exclusion criteria included a recent (⩽6 months) heart attack or admission to hospital
with chest pain, chest pain at rest, significant symptoms of palpitations, severe narrowing of the
aortic valve, significant breathlessness, fluid build-up or swelling, lung clots, recent heart inflam-
mation or pericardial inflammation. All participants were offered written and verbal information
Hately and Mandic 3

about the study and gave written consent to participate. This study was approved by the University
of Otago Human Ethics Committee.

Procedures
In this cross-sectional study, participants performed a 7-day objective PA assessment using accel-
erometers. In addition, participants attended one 2-hour appointment, either at the University of
Otago or at the Taieri Bowling Club. Each participant completed a physical function assessment
and a series of questionnaires about sociodemographic characteristics, medical history, quality of
life and PA habits. All assessments were conducted by the first author (G.H.).

Community-based maintenance CR
Both CAD and non-CAD participants participated in one of two local community-based CR pro-
grammes. Each club offered weekly group exercise sessions, lasting for ~60 minutes. Each exer-
cise session involved a mixture of aerobic, resistance, flexibility and balance training. All sessions
were led by a physiotherapist or exercise professional (for details see Mandic et al., 2018). Both
CR clubs allowed individuals without a history of CAD to participate. The Otago Phoenix Club
allowed its members to bring their spouses as a support person, whereas the Taieri Fit and Fun
Group being a CR club, was also a community exercise club.

Outcome measures and assessment procedures

CR attendance.  Records of attendance and CR club membership duration were provided by clubs
and were used to calculate the total attendance rate of each participant for the previous 12 months.
Attendance rates were calculated by dividing the number of attended sessions by the number of
available CR sessions since January 2016 (or the participants start date in CR), and the date of
assessment.

Sociodemographic characteristics and medical history.  Participants self-reported sociodemographic

information including age, gender, ethnicity, education, marital and employment status. In addi-
tion, participants reported medical history including cardiovascular risk factors (high blood pres-
sure, cholesterol, diabetes, obesity and smoking), co-morbidities and current medications.

Accelerometer-assessed PA.  Each participant was given an accelerometer (ActiGraph GT3X, Acti-
Graph Corporation, Pensacola, FL) as well as a log sheet at their appointment. Participants were
instructed to wear their accelerometers on the right hip for 7 days, with a minimum of 10 hours each
day except when sleeping or during water-based activities. To promote compliance and remind
participants to wear their device, participants were asked to record in a log the time they put on and
took off their device during the day and reasons for not wearing an accelerometer. Only partici-
pants who wore their accelerometer for a minimum of 7 days with ⩾10 hours/day of wear time
were included in the final analysis using the MeterPlus software. Only one participant was non-
compliant with the accelerometer wear time requirements.
Accelerometer sampling was set to record data in 60-second epochs, with Freedson Adult cut
points used to determine estimates of time spent in different intensities of PA (non-wear: −999 to
−999, sedentary 0 – 100, light 101 – 1951, moderate 1952 – 5,724, vigorous 5,725 – 15000;
Freedson et al., 1998). The average time spent in specific PA intensities per day was calculated by
summing together the total minutes participants accumulated within each intensity (sedentary,
4 Health Education Journal 00(0)

light, moderate, vigorous) using all 60-second epoch periods divided by the total number of valid
wear days. Achievement of current PA guidelines was calculated by summing the number of days
during which participants met the daily criteria for moderate- and vigorous-intensity PA (⩾30 min-
ute/day) (Garber et al., 2011).

Self-reported PA.  Habitual PA was assessed using the International Physical Activity Questionnaire-
Short Form (IPAQ-SF; test–retest reliability with median ICC of ~.80; Craig et al., 2003). Each
participant reported frequency and duration spent participating in light, moderate and vigorous
intensity PA as well as time spent in sedentary activities in the previous week. The results of this
questionnaire were used to categorise participants as inactive, minimally active or health-promot-
ing physically active.

Physical function.  Physical function was assessed using a Short Physical Performance Battery, hand-
grip strength test, 30-second chair stand, one-foot balance test, 6-minute walk test and a 10-m
shuttle walk test. All testing protocols have been previously described in detail elsewhere (Mandic
et al., 2013a) and are briefly summarised below.

Short physical performance battery.  Balance was assessed with three hierarchical standing positions
held for up to 10 seconds each (feet side-by-side, semi-tandem and tandem positions; Puthoff,
2008). Gait speed was measured by two 4-m standard walking speed tests and better score was
used in the analysis (Puthoff, 2008). Repeated five chair-stand tests were also performed (Puthoff,
2008). Each test was scored on individual subscales between 0 (unable to complete the task) and 4
(highest level of performance). A total score was calculated from all three subscale scores ranging
from 0 (severe limitations) to 12 (minimal limitations).

Muscle strength.  Upper body muscle strength was assessed by dynamometer handgrip strength test-
ing (Lafayette Dynamometer Model 78010) with participants in a sitting position and elbow bent
at 90°. Participants performed the test on both hands three times, with a minimum of 30 seconds
rest between the assessments to ensure recovery. Handgrip strength index was determined by the
average of the highest values from both hands. Lower body muscle strength was assessed using a
30-second chair stand test that was performed twice with the best score used in the final analysis.

10-m incremental shuttle walk test.  In this test, participants walked back and forth between two
cones 10-m apart for up to 12 minutes in sync with an auditory signal (Singh et al., 1992). The test
began with a speed of ~1.8 km/hour and progressively increased every minute by ~0.6 km/hour
until it reached the maximum speed of 8.5 km/hour at 12 minutes. The test was terminated when
participants experienced symptoms of exercise intolerance or could not maintain the pace. Each
participant performed this test only once.

6-minute shuttle walk test.  In this test, participants were instructed to walk around a 30-m loop for
6 minutes (Wright et al., 2001) and were allowed to jog (Mandic et al., 2013a). The test was per-
formed twice with a minimum of 1 hour between tests (Mandic et al., 2013a). The furthest distance
walked was used in the final analysis. Estimated VO2peak was calculated using the following previ-
ously published formula designed for elderly CAD patients (Mandic et al., 2013a).

VO2peak = 0.015 x 6MWT distance ( m ) + 0.239 x 30 - second chair stand ( n )

− 0.218 x body fat (% ) + 12.258
Hately and Mandic 5

Quality of life.  Quality of life was assessed using the validated SF-36 short form questionnaire
(Failde and Ramos, 2000). This self-report questionnaire consisted of 36 items relating to 8 broad
health domains including physical function, bodily pain and limitation, general health, vitality,
social function as well as general emotional and mental health. Scoring of each domain ranged
from 0 (poorest level of function) to 100 (highest level of function).

Anthropometry and body composition. Height was measured using a custom-built stadiometer.

Weight was measured using an electronic scale (A&D scale UC321, A&D Medical). Body mass
index was calculated using weight in kilograms divided by height squared (kg/m2). Waist circum-
ference was measured using a metal tape at the narrowest part of the torso and hip circumference
around the widest part of the buttocks, both to the nearest 1 mm (Mandic et al., 2013a). Waist-to-
hip ratio was calculated by waist circumference divided by hip circumference. Both waist and hip
measurements were taken twice in a standing position, with the averages used in the final analysis.
Body composition (proportion of body fat and muscle mass) was measured using a BioImpedance
scale (InBody 230, Bioscape Co Ltd, Seoul, Korea) as described previously (Mandic et al., 2013a).

Statistical analysis
Descriptive statistics were used to analyse sociodemographic characteristics, medical history and
medications for both CAD and non-CAD groups. Differences between groups were examined
using the paired t-test for continuous variables and chi-square test for categorical variables. Data
are reported as frequency (percentage) for categorical variables and M ± SD for continuous varia-
bles. p < .05 was deemed statistically significant. Data were analysed using the SPSS Statistical
software package Version 24.0 (SPSS, Chicago, IL).

Results
A total of 39 elderly individuals (13 CAD and 26 non-CAD) completed all study assessments
(Table 1). Most participants were married, retired and had less than a university education without
significant differences between CAD and non-CAD groups (Table 1). Compared with the non-
CAD group, a greater proportion in the CAD group had dyslipidemia and were taking cardiovas-
cular medications (aspirin, lipid lowering agents, beta blockers and ACE-inhibitors) and a lower
proportion was obese (Table 2).
Objectively measured PA data showed that CAD group performed twice as much of moderate-
to-vigorous PA per week compared with the non-CAD group (329.7 ± 233.3 vs 160.6 ± 149.5 min-
utes, p = .013; Figure 1). On average, the CAD participants achieved the recommended daily
amount of PA (⩾30 minutes of MVPA/day) on more days per week compared with the non-CAD
group (Table 3). The CAD group self-reported being more physically active per week (4.7 ± 2.3 vs
3.3 ± 1.7 days/week, p = .048) as well as spending significantly less time being sedentary per day
compared with the non-CAD group (Table 3). Based on the self-report using IPAQ-SF question-
naire, 79.5% of all participants self-reported that they had performed PA at the same intensity for
the past 12 months and were not intending to change PA habits within the next 6 months. No signifi-
cant differences were observed for any quality of life subscale (Table 4). Furthermore, there was
no significant difference for any measure of physical function, including the Short Physical
Performance Battery, handgrip and lower body strength tests or exercise capacity tests (Table 5).
Body composition (body fat and muscle mass percentages) was significantly more favourable in
the CAD group compared with that of the non-CAD group (Table 5).
6 Health Education Journal 00(0)

Table 1.  Sociodemographic characteristics, programme use and coronary artery disease.

Variable Total CAD Non-CAD p value

n = 39 n = 13 n = 26
Age (years) 70.7 ± 5.5 71.8 ± 7.1 70.1 ± 4.6 .362
Gender [n (%)] – – – –
 Men 11 (28.2) 3 (23.1) 8 (30.8) –
 Women 28 (71.8) 10 (76.9) 18 (69.2) .615
Ethnicity [n (%)] – – – –
  New Zealand European 35 (89.7) 12 (92.3) 23 (88.5) –
 Māori 1 (2.6) 1 (7.7) 0 (0.0) –
 Other 2 (5.1) 0 (0.0) 2 (7.7) .709
Married [n (%)] 30 (76.9) 9 (69.2) 21 (80.8) .199
Retired [n (%)] 30 (76.9) 10 (76.9) 20 (76.9) .263
University degree [n (%)] 10 (25.6) 2 (15.4) 8 (30.8) .213
CR Membership length (years) 5.6 ± 6.8 7.7 ± 9.9 4.5 ± 4.4 .170
CR Attendance in previous year (%) 49.9 ± 28.5 46.2 ± 28.4 51.8 ± 29.0 .570
Distance from CR club (km) 5.5 ± 5.9 7.2 ± 6.5 4.6 ± 5.5 .192
Time since first cardiac event – 11.2 ± 10.1 – –
Time since last cardiac event – 7.4 ± 5.3 – –
CAD [n (%)] – – – –
 Angina 9 (23.7) 9 (69.2) 0 (0.0) –
  Myocardial infarction 6 (15.4) 6 (46.2) 0 (0.0) –
 Angioplasty/stent 5 (12.8) 5 (38.5) 0 (0.0) –
  Bypass surgery 11 (28.2) 11 (84.6) 0 (0.0) –
  Heart failure 1 (2.6) 1 (0.8) 0 (0.0) –

CAD: coronary artery disease; CR: cardiac rehabilitation.

Discussion
Individuals with heart disease have poor long-term adherence to achieving recommended PA levels
(Hansen et al., 2010). This study compared PA, physical function and quality of life in elderly
individuals with CAD and their non-CAD peers participating in community-based, maintenance
CR. In this study, individuals with CAD were more physically active when PA was measured
objectively using accelerometers, but their self-reported PA was not significantly different from
their non-CAD peers. However, despite significant differences in PA duration, objectively meas-
ured PA results showed that only approximately 26% of all study participants met current mini-
mum PA guidelines of for adults ⩾30 minutes per day, ⩾5 days a week. Body composition measures
such as percentage of body fat and muscle mass were significantly more favourable in the CAD
group compared to the non-CAD group. The groups were not different with respect to quality of
life and physical function.
It has long been the common practice in previous studies investigating PA habits of CR partici-
pants to incorporate self-report questionnaires, most of which are prone to overestimation of actual
PA levels (Boon et al., 2010), with only a few studies measuring PA objectively using accelerom-
eters (Ayabe et al., 2004; Horwood et al., 2015; Jones et al., 2007). Previous studies based on self-
reported PA showed that the presence of CAD-related symptoms contributed to reducing overall
PA levels in CAD patients (Garber et al., 2011; Grace et al., 2009). In this study, using objective
measurement of PA, CAD participants in long-term CR programmes achieved on average more
Hately and Mandic 7

Table 2.  Clinical characteristics of participants.

Variable Total CAD Non-CAD p value

n = 39 n = 13 n = 26
Risk factors [n (%)]  
 Hypertension 24 (63.2) 10 (76.9) 14 (53.8) .163
 Dyslipidaemia 21 (53.8) 10 (76.9) 11 (42.3) .041
 Obesity 9 (23.1) 0 (0.0) 9 (34.6) .000
 Smoking 4 (10.5) 1 (8.3) 3 (11.5) .709
 Diabetes 2 (5.1) 2 (5.1) 0 (0.0) .608
  Family history of CAD 14 (35.9) 3 (23.1) 10 (76.9) .337
  Total number of modifiable risk factorsa (n) 1.7 ± 1.1 2.1 ± 1.1 1.5 ± 1.1 .076
Other medical conditions [n (%)]  
 Asthma 8 (20.5) 2 (15.4) 6 (23.1) .575
  Breast/colon/prostate cancer 8 (20.5) 2 (15.4) 7 (26.9) .420
 Depression 1 (2.6) 1 (7.7) 0 (0.0) .152
 Anxiety 1 (2.6) 0 (0.0) 1 (3.8) .474
 COPD 1 (2.6) 0 (0.0) 1 (3.8) .474
 Arthritis 18 (46.2) 5 (38.5) 13 (50.0) .496
 Backpain 11 (28.2) 4 (30.8) 7 (26.9) .801
 Osteoporosis 4 (10.3) 1 (7.7) 3 (11.5) .709
 Stroke 1 (2.6) 0 (0.0) 1 (3.8) .100
Symptoms [n (%)]  
  Chest discomfort with exertion 9 (23.1) 8 (61.5) 1 (3.8) .000
  Shortness of breath 7 (17.9) 5 (38.5) 2 (7.7) .018
  Dizziness, fainting or blackouts 6 (15.4) 4 (30.8) 2 (7.7) .060
  Lower leg cramps with short walks 4 (10.3) 3 (23.1) 1 (4.3) .062
  Musculoskeletal pain 5 (12.8) 2 (15.4) 3 (11.5) .735
Cardiac medications [n (%)]  
 Aspirin 12 (30.8) 10 (76.9) 2 (7.7) .000
  Lipid-lowering agents 19 (48.7) 10 (76.9) 9 (34.6) .013
  Beta blockers 9 (23.1) 8 (61.5) 1 (3.8) .001
 ACE-inhibitors 15 (38.5) 9 (69.2) 6 (23.1) .005
  Calcium channel blockers 3 (7.7) 2 (15.4) 1 (3.8) .202
 Diuretics 2 (5.1) 1 (7.7) 1 (3.8) .608
 Nitrates 1 (2.6) 1 (7.7) 0 (0.0) .152
  GTN spray 1 (2.6) 1 (7.7) 0 (0.0) .152

ACE: angiotensin converting enzyme; CAD: coronary artery disease; COPD: chronic obstructive pulmonary disease;
GTN: glyceryl trinitrate.
aModifiable risk factors include hypertension, dyslipidaemia, smoking, diabetes and obesity.

than the recommended minimum of 30 minute of MVPA per day and also accumulated more daily
MVPA compared with their non-CAD peers. Our previous research has shown that CAD patients
who regularly participated in community-based CR exercise sessions were more physically active,
had greater health concerns and perceived more significant benefits to regular participation in CR
compared with their CAD peers who participated in maintenance CR less frequently or did not
participate at all (Horwood et al., 2015). Therefore, perceived benefits of PA and existing health
concerns among CAD patients participating in community-based maintenance CR may in part
8 Health Education Journal 00(0)

600 *

Time spent in moderate to vigorous physical

500

acvity (mins/ week)

400

300

200

100

0
CAD Non-CAD

Figure 1.  Objectively measured moderate-to-vigorous physical activity per week in CAD and non-CAD groups.
CAD: coronary artery disease.
*p < .05.

explain higher level of PA in CAD versus non-CAD individuals in our study. However, it is impor-
tant to emphasise that only a quarter of all participants in this study achieved the minimum PA
guidelines for adults (⩾30 minutes of MVPA on ⩾5 days/week), which is consistent with previous
studies in CAD patients (Ayabe et al., 2004; Jones et al., 2007). We previously reported similar
findings from self-report measures of PA in a different cohort of participants from the same CR
programmes (Mandic et al., 2015).
Previous investigations reported that individuals with heart disease have poor long-term adher-
ence to achieving recommended PA levels (Hansen et al., 2010). In contrast, cardiac patients par-
ticipating in maintenance CR programmes were more likely to regularly perform PA and meet the
recommended PA levels (Bock et al., 2003). Using self-reported measure of PA, most participants
(97%) in the current study were categorised as being physically active compared with 26% when
PA was assessed objectively using accelerometers. The overestimation of self-reported PA in this
study highlights inaccuracies associated with self-report, including recall bias as well as potential
cognitive challenges faced by elderly individuals when recalling their PA habits (Washburn et al.,
1990). Previous studies showed that less active adults were more likely to misperceive the intensity
of PA, particularly for moderate and vigorous intensity PA compared with their more active peers
(Boon et al., 2010; Duncan et al., 2001). Therefore, it is possible that the overestimation of self-
reported PA in elderly adults may reflect their an inability to accurately perceive the intensity of PA
performed on a daily basis. Due to the the challenges associated with self-reported PA and the
small sample size in this study, caution is warranted when interpreting these results.
In this study, elderly individuals with CAD participating in community-based CR programme
had a more favourable body composition compared with their non-CAD counterparts. Mandic et al.
(2015) previously reported similar findings in a different cohort of participants recruited from the
same CR clubs several years earlier. It might be suggested that the more favourable body composi-
tion of the CAD participants was due to their significantly higher overall PA levels, as regular exer-
cise can improve body composition (Thompson et al., 2003). However, we also showed that during
a 1.6-year follow-up of a similar cohort of CAD patients participating in maintenance CR unfavour-
able changes in body composition occurred regardless of attendance to CR and self-reported PA
Hately and Mandic 9

Table 3.  Objectively measured physical activity and guideline achievement.

Variable Total CAD Non-CAD p value

n = 38 n = 13 n = 25
Objectively measured PA  
Total time spent in PA (minute/day) 320.1 ± 69.4 351.7 ± 61.9 303.9 ± 68.7 .044
 Sedentary 514.6 ± 82.5 478.9 ± 77.8 533.1 ± 80.1 .054
 Light 289.8 ± 56.1 306.7 ± 50.3 281.0 ± 57.9 .184
 Moderate 30.0 ± 27.9 44.0 ± 34.6 22.8 ± 21.2 .024
 Vigorous 0.2 ± 0.7 0.5 ± 0.9 0.1 ± 0.5 .141
Participants meeting PA guidelinesa 10 (26.3) 5 (38.5) 5 (20.0) .220
Average number of days with ⩾30 minute of 2.7 ± 2.6 3.8 ± 2.2 2.1 ± 2.6 .042
moderate-to-vigorous PA
Self-reported PA  
Brisk walking  
  Frequency (days/week) 4.9 ± 2.2 5.1 ± 1.9 4.7 ± 2.4 .585
  Duration (minute/week) 50.0 ± 44.6 53.3 ± 32.8 48.4 ± 49.8 .758
Moderate-intensity activity  
  Frequency (days/week) 3.8 ± 2.0 4.7 ± 2.3 3.3 ± 1.7 .048
  Duration (minute/week) 75.3 ± 74.0 81.9 ± 78.2 72.0 ± 73.2 .699
Vigorous-intensity activity  
  Frequency (days/week) 2.3 ± 1.5 2.50 ± 1.6 2.3 ± 1.5 .664
  Duration (minute/week) 42.1 ± 56.5 50.8 ± 75.7 37.6 ± 44.8 .503
Self-reported sedentary behaviour  
Average time being sedentary per day (hours/day) 14.6 ± 8.4 10.7 ± 7.4 16.5 ± 8.3 .042
  Watching TV (hours/day) 2.8 ± 1.4 2.2 ± 1.5 3.2 ± 1.4 .040
  On computer (hours/day) 1.5 ± 3.3 0.65 ± 1.1 1.9 ± 3.9 .234
  Driving (hours/day) 3.9 ± 14.5 7.6 ± 24.8 2.1 ± 3.0 .444
  Reading (hours/day) 2.3 ± 3.1 2.0 ± 3.2 2.5 ± 3.1 .693
  Sitting (hours/day) 1.4 ± 1.6 1.4 ± 1.5 1.4 ± 1.6 .986
  Sleeping (hours/day) 7.4 ± 1.7 7.3 ± 2.4 7.4 ± 1.7 .848

CAD: coronary artery disease; PA: physical activity.

aNumber of participants achieving current minimum PA guidelines for adults of ⩾30 minutes of moderate-to-vigorous

PA per day, ⩾5 days per week.

Table 4.  Quality of life subscale domains.

Variable Total CAD Non-CAD p value

n = 39 n = 13 n = 26
Quality of life subscales  
  Physical functioning 85.2 ± 14.4 87.3 ± 13.9 84.2 ± 14.8 .537
  Role limitations – physical 88.1 ± 17.8 85.1 ± 22.3 89.7 ± 15.3 .457
  Role limitations – emotional 95.1 ± 12.2 91.7 ± 14.8 96.8 ± 10.6 .280
  Bodily pain 79.9 ± 22.3 84.8 ± 20.4 77.6 ± 23.2 .937
  General health 78.9 ± 14.4 73.1 ± 17.9 81.9 ± 11.6 .071
 Vitality 75.0 ± 11.2 74.5 ± 13.2 75.2 ± 10.5 .371
  Social function 94.1 ± 13.5 93.7 ± 12.5 94.2 ± 14.2 .266
  Mental health 87.2 ± 10.1 83.7 ± 12.1 88.8 ± 8.7 .142
10 Health Education Journal 00(0)

Table 5.  Anthropometry and physical function.

Variable Total CAD Non-CAD p value

n = 39 n = 13 n = 26
Anthropometry and body composition  
  Height (cm) 162.8 ± 8.4 165.2 ± 11.4 161.7 ± 6.3 .315
  Weight (kg) 72.4 ± 13.7 73.3 ± 13.5 72.0 ± 14.0 .788
  Body mass index (kg/m2) 27.2 ± 4.7 26.5 ± 3.5 27.6 ± 5.2 .493
  Waist circumference (cm) 89.7 ± 13.1 91.5 ± 13.2 88.7 ± 13.1 .539
  Hip circumference (cm) 102.1 ± 12.3 98.3 ± 10.6 104.0 ± 12.8 .177
  Waist-to-hip ratio 0.87 ± 0.10 0.91 ± 0.13 0.86 ± 0.10 .114
  Body fat (%) 33.4 ± 9.5 27.5 ± 8.4 36.5 ± 8.7 .004
  Muscle mass (%) 66.3 ± 10.3 72.5 ± 8.4 63.0 ± 9.8 .022
Physical function  
  30-second balance test (second) 22.9 ± 8.7 23.9 ± 7.7 22.5 ± 9.3 .646
  30-second chair stand test (n) 14.8 ± 4.7 15.5 ± 4.3 14.5 ± 4.9 .570
  Handgrip strength index (kg/F) 28.2 ± 9.5 32.4 ± 12.2 26.1 ± 7.6 .109
  Short Physical Performance Battery score (0–12) 11.2 ± 1.5 11.6 ± 0.8 11.0 ± 1.7 .267
  10-m shuttle walk test duration (minute) 7.7 ± 1.5 7.5 ± 1.4 7.8 ± 1.6 .685
  6-minute walk test distance (m) 452.9 ± 103.9 456.4 ± 73.8 457.6 ± 63.5 .959
 Estimated 6-minute walk test VO2peak (mL/kg−1/ 14.8 ± 5.2 16.6 ± 5.5 13.8 ± 4.9 .124
minute−1)

VO2peak: peak oxygen uptake.

levels (Mandic et al., 2013a). In contrast, a previous investigation examining the effects of long-
term (>1 year) participation in CR reported greater improvements in participants’ body weight and
percentage of body fat compared to the cardiac patients who participated in a standard-length
(3 month) CR programme (Brubaker et al., 1996). Further investigation into the effects of long-term
CR on body composition is warranted, as unfavourable body composition can play a significant role
in the progression of CAD (Yusuf et al., 2005).
Previous studies have reported that significant improvements in multiple domains of elderly
CAD patients’ quality of life can occur after 6 months of participation in CR (Seki et al., 2003). In
this study, no significant differences in quality of life variables were observed between the elderly
CAD patients participating in the long-term community maintenance CR programme compared to
non-CAD participants. Therefore, the lack of significant difference in quality of life between the
groups may be related to participants’ long-term attendance to community-based CR programmes,
as improvements in quality of life are expected at the start of the programme but are likely to level
out in the long term. Alternatively, it is possible that CAD participants who chose to participate in
community-based CR programmes and in this study already had a high quality of life. Previous
research showed that increased PA, improved physical function and more favourable body compo-
sition were related to better quality of life in elderly individuals with and without CAD (Rejeski
and Mihalko, 2001).
In this study, there were no significant differences in measures of muscle strength, physical
function or exercise capacity between CAD and non-CAD participants. We previously reported
similar findings in a different cohort of CAD and non-CAD participants from the maintenance CR
programmes (Mandic et al., 2013b). Another study reported improvements in physical function
among elderly cardiac patients after 1 year of participation in a CR programme that involved
strength, balance and coordination exercises (Molino-Lova et al., 2011). The lack of difference in
Hately and Mandic 11

muscle strength, physical function or exercise capacity between CAD and non-CAD participants
in the current study may be explained by participants’ adaptation to the maintenance CR exercise
programme and potential limitations of a ‘ceiling effect’ of a physical function test used in this
study. A ‘ceiling effect’ has been reported previously when physical function in elderly individuals
was assessed using the Short Physical Performance Battery (Rengo et al., 2017).

Limitations
This study has several limitations, including recruitment of participants from only two CR clubs in one
city, set p value at < .05 despite multiple individual statistical tests, small sample size, and potential
recruitment bias with self-selection of highly motivated and physically active CR participants who
may be non-representative of CAD and non-CAD participants of community-based CR programmes.
Lack of sample size calculation prior to the study and small number of study participants had signifi-
cant implications on limiting the statistical power for detecting true differences between the groups in
this study. Furthermore, the self-selection of highly motivated participants may have introduced prob-
lems with recall and social desirability bias when self-reporting PA habits. Accelerometers have lim-
ited sensitivity to non-ambulatory exercises such as cycling, swimming or upper extremity movement
(Murphy, 2009). Since current PA guidelines for adults were developed using mainly self-reported
data, using the same guidelines for classifying participants as meeting or not meeting PA guidelines
based on accelerometry data may be misleading. Furthermore, as this study recruited participants from
only two local CR clubs, the similar physical function and quality of life may be related to the nature
of this population of CAD and non-CAD individuals rather than the differences between CAD and
non-CAD individuals overall. To reduce the potential bias of self-selection and increase the generalis-
ability of the study findings, future studies should aim to recruit from a larger population of commu-
nity-based, maintenance CR programmes from multiple geographic settings.

Conclusion
Elderly CAD patients who participate in community-based maintenance CR had higher levels of PA,
but similar physical function and quality of life compared to their non-CAD peers. Therefore, long-
term participation in community-based CR may encourage CAD patients to be physically active and
maintain physical function and quality of life vital for their independence at the similar level as their
non-CAD peers. These encouraging findings should be confirmed in a larger, sufficiently powered
study of elderly CAD patients from multiple community-based maintenance CR programmes.

Acknowledgements
We thank the Otago Phoenix Club and Taieri Fit and Fun for their support, and study participants for their
contribution. We also thank Tessa Pocock and Chiew Ching Kek for their help with data collection. Research
materials and data related to this paper can be requested from the corresponding author.

Funding
The author(s) disclosed receipt of the following financial support for the research, authorship, and/or publica-
tion of this article: This study was funded by an internal research grant from the School of Physical Education,
Sport and Exercise Sciences, University of Otago.

ORCID iDs
Garrick Hately https://orcid.org/0000-0002-6381-2693
Sandra Mandic https://orcid.org/0000-0003-4126-8874
12 Health Education Journal 00(0)

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