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Health-Related Quality of Life for Patients with Cardiovascular Disease after a

Coronary Artery Bypass Graft A Systematic Review

Article in Indian Journal of Public Health Research and Development · January 2019
DOI: 10.5958/0976-5506.2019.02261.7

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 DOI Number: 10.5958/0976-5506.2019.02261.7

Health-Related Quality of Life for Patients with

Cardiovascular Disease after a Coronary Artery Bypass Graft:
A Systematic Review

Tintin Sukartini1, Hidayat Arifin1, Ulfa Nur Rohmah1, Dian Rizki Ramadhani1
1
Faculty of Nursing, Universitas Airlangga, Surabaya, Indonesia

ABSTRACT
CABG can affect health-related quality of life (HRQoL) and it can take a long time to improve. The following
question was raised: ‘How long does it take for the HRQoL of patients with a Coronary Artery Bypass Graft
(CBAG) to increase?’ The aim was to analyze the recent scientific production of HRQoL in cardiovascular
patients with CABG. The PRISMA approach was used and we examined articles from Scopus, EBSCO and
ProQuest that were published between 2014 - 2018. We used “health related quality of life”, restricted our
search to “coronary artery bypass graft” and used “after” in the title, keywords and abstract connected by
the Boolean operator “AND”. SF-36 was used to assess the HRQoL and it increased within six months after
CABG. This was influenced by self-control, obesity, age, gender, emotions and personality. Improving the
patient’s quality of life is key for the nurses to control so then the heart surgery patients become prosperous
and thus reduce their morbidity and mortality.

Keywords: health related quality of life; coronary artery bypass graft; cardiovascular disease

Introduction quality of life, because individuals not only want a long

The number of individuals suffering from
cardiovascular disease in the world continues to increase
every year. Cardiovascular disease is the foremost most
disease in Indonesia, ischemic heart disease specifically.1
The most common medical treatment for heart disease is
Coronary Artery Bypass Grafting (CABG) for coronary
heart disease. Medical management can affect the quality
of life of patients with cardiovascular disease.2 The act of
limiting activities, restricting eating and making changes
in their lifestyle in post-CABG patients is an effort that
is required to maintain the quality of life in patients after
medical management. Only a few patients experience
depression and this interferes with HRQoL.3 Attention
must be directed to the more important aspects, namely
Corresponding Author:
Hidayat Arifin
Department of Medical Surgical Nursing,
Faculty of Nursing, Universitas Airlangga,
Kampus C Mulyorejo, Surabaya, Indonesia
Phone: (031) 5914042, Fax. (031) 5915551, Indonesia
Email: hidayat.arifin-2018@fkp.unair.ac.id
life but they also want to improve their quality of life.4
Improving the quality of life is also one indicator
of the success of CABG operations. This includes
symptom prevention and management behaviour post-
CABG recovery. The patients also believe and have hope
about controlling their illness and treatment in the new
approach and they seek to clarify the various symptoms
and adaptations that are useful in terms of quality of
life.5The importance of measuring the impact of medical
interventions on quality of life related to patient health
(HRQoL) is emphasized. HRQoL is also seen as how
the results of the treatment can successfully provide
potential changes to the lives of the patients.6
Some studies also suggest important results in terms of
increasing HRQoL, such as several factors being involved
namely comorbid diseases, depression, anxiety and the
incidence rate of cardiovascular invasive procedures.7 But
up until now, although some studies say that there is a
decrease in quality of life after CABG, it is but not yet
known in detail the factors that contribute to quality of life
in patients who have had CABG. The purpose of the study
was to analyze recent scientific production about HRQoL
in cardiovascular patients with CABG.
 Indian Journal of Public Health Research & Development, August 2019, Vol.10, No. 8
Method
Research design and search strategy: The systematic
review research design resulted from and focused on
the latest research over the last 5 years. This study used
the Preferred Reporting Items for Systematic Reviews
and Meta-Analyzes (PRISMA) approach. The process
of searching the articles was electronic. The data was
obtained from Scopus, ProQuest, and EBSCO. The
literature review used the keywords ‘Health related
Quality of Life’, ‘After’ and ‘Coronary Artery Bypass
Graft’. In the article search, we used the Boolean operator
“AND”. After a number of articles was obtained, the
researcher then selected them again according to the
specified inclusion and exclusion criteria. The article
searching process was carried out from August to
October 2018. The search for articles used keywords
that had been determined by the researchers and they
also provided limits as per the inclusion and exclusion
criteria. The data obtained from Scopus, EBSCO
and ProQuest were then selected one by one by the
researchers to determine their suitability. After obtaining
articles that were in accordance with the researchers’
intentions, the articles were analyzed one by one and
grouped to get the results. The next step was to discuss
what had been found based on the points obtained from
the results.
Inclusion and Exclusion Criteria: The desired articles
were articles published between 2014 – 2018 and articles
written in English focusing on the keywords in the search
for relevant articles. Articles with samples that did not
focus on patients with PCI and CABG, the discussion
of articles looking at outside life quality (HRQoL) as
well as articles based on a systematic review, narrative
review, thesis, books or chapters, abstracts and editorials
were not used in this study.
Results
The initial literature search returned 123 abstracts
(71 from SCOPUS, 39 from EBSCHOHOST and 20
from PROQUEST). After reviewing the abstracts for
relevance and matching them with the inclusion criteria,
45 articles were selected for a full-text review (34
from SCOPUS, 15 from EBSCHOHOST and 6 from
PROQUEST). There were 24 duplicate articles and 2
articles published in 2013 which were excluded. Finally,
19 articles were chosen to be reviewed. The studies
were heterogeneous. There were 13 cohort prospective/
2607
prospective observational studies, 4 randomized trial
studies, 1 longitudinal study and 1 descriptive qualitative
study [Figure 1].
The general instruments used were 13 studies
analyzed with The Short-Form Health Survey (SF-36
and SF-12). The Short-Form Health Survey (SF-36)
questionnaire has been proven to be the most widely
used tool to evaluate quality of life among patients
undergoing cardiac treatment and surgery.8
Most of the studies stated the majority of respondents’
HRQoL scores increased after undergoing CABG
surgery, both in the physical and mental domains. Two
years after CABG, the clients became more confident in
themselves and their health, with 81% of patients having
a good quality of life.2Post-CABG HRQoL is influenced
by a variety of factors, including the type of CABG
(on-pump or off-pump), self-control related to health,
obesity, age, gender, type-D personality and the role of
emotional physical roles, vitality and social functions.6
Figure 1: Flowchart of articles selected in the
systematic review; the selection process using
PRISMA (Preferred Reporting Items for Systematic
Reviews and Meta-Analyzes). The articles were
obtained from SCOPUS, EBSCO and ProQuest
totaling 123 articles. The final studies included in
the synthesis was 19 articles.
Discussion
There are several stages related to behaving healthily.
The stages include precontemplation (in 6 months,
not yet interested in making changes), contemplation
(considering changes in the next 6 months), preparation
(trying to make changes but not and wanting to do it
again the following month), action (actively developing
 2608 Indian Journal of Public Health Research & Development, August 2019, Vol.10, No. 8
strategies to make changes, sometimes after almost
6 months with time and effort to commitment) and
maintenance (changes continue, starting 6 months after
the action phase begins). The health-related quality of
life increased in patients 6 months after CABG was
performed.2,3,9,11-16 However, 12 months after CABG was
done and even for years after, there was an increase in
the quality of life as well. The most common occurred
after 6 months. This may occur because patients
who have long been hospitalized may have begun to
experience boredom or they may be in the action stage.
In addition, depression before surgery causes a high
level of hospitalization. Prolonged surgical pain can last
for up to 6 months and they may have difficulty returning
to their previous activities. One needs to consider the
effect post-CABG cardiac rehabilitation on older elderly
people, as this has an adverse impact on CABG.3
Psychological morbidity includes depression,
anxiety, personality and emotional roles reinforcing
a decrease in the quality of life of the patients.13this
improvement does\\nnot seem to be realized in
all patients who had undergone CABG surgery.\\
nObjective: The aim of this study was to test the direct
and indirect\\ninfluence of personality trait Type D on
no change-deterioration\\ntrajectories HRQoL and the
mediating influence of increased symptoms of\\nanxiety
and depression. Methods: The hypothesized influence
of\\npersonality trait Type D on the relationship between
increased anxiety\\nand depression and no change-
deterioration trajectories in HRQoL was\\ntested with
path analysis using structural equation modeling.
Results:\\nThe results of the current study show that
Type D personality comprised\\na vulnerability factor
for poor patient-reported outcomes (ie, HRQoL and\\
ndistress,21coronary artery bypass graft (CABG,15,3 Over
the years, CABG measures have reduced the significant
mortality rates but strangely, there are still patients
who have a psychological condition even 5 years post-
CABG.22 The lack of resolution for the psychological
problems of patients after rejection can cause recurrent
heart attacks. For that, the nurse should facilitate by
helping and relaxing the patients by providing sedatives.23
The female gender is reported as slowing the increase
in HRQoL due to low coping mechanisms and changing
role perspectives. Women often suffer from chest pain
in the arterial area in an epicardial coronary.15There
was a gender difference in the biological process that
transmits and modulates pain signals; the nervous
system of men and women is different when it comes to
detecting and responding to pain (pain sensitivity) and
the emotional cognatic response to pain differs between
men and women. The female gender therefore correlates
with a quality of life related to low health.15 Pain is also
associated with the quality of life of patients who have
carried out CABG.24 It is known that the standard blood
vessels used for CABG are the safina magna vein and
the left internal mammary artery of the chest. Although
the prevalence of severe pain decreases year by year and
modern analgesic methods are used, chronic pain after
CABG remains a concern because the incidence rate of
chronic pain has reached 30-50%.12Chronic pain after
CABG also relates to the subsequent cost estimates for
the health care and social support systems. This post-
operative CABG pain may also be associated with the
somatic, visceral and neuropathic conditions.25intensity,
location, and the presence of neuropathic pain, according
to the Preferred Reporting Items for Systematic Reviews
and Meta-Analyses. The review comprised 3 phases:
a methodological assessment of 6 different databases
identifying potential articles and screening for inclusion
criteria by 2 independent reviewers; data extraction;
and study quality assessment. Meta-analysis was used
to estimate the pooled incidence rates using a random
effects model. We have identified 442 potentially
relevant studies through database searching. A total of
23 studies (involving 11,057 patients
The perception of post-CABG training has an impact
on HRQoL. Bad perceptions becomes a barrier within
cardiac rehabilitation training. It is known that poor
diet and poor exercise are the independent risk factors
in developing worsening CAD post-CABG surgery.
Exercise, lifestyle modification and diet after CABG
surgery is important to pay attention to in order to avoid
future risks to one’s health.26The differences in age do
not really show as having a specific impact on HRQOL.
The patients who are <60 year old age undergoing
CABG have worse outcomes than those of an older
age. Age is related to cognitive processes. Cognitive
differences are usually higher in older people compared
to middle-aged adults.27Clinical performance included
pulmonary function, which is a physical component
related to a decrease in lung function that is also related
to an increase in CRP and post-operative blood cortisol
concentrations and a greater preoperative IVC.10,28-30
HRQoL in this context is where the patients define how
 Indian Journal of Public Health Research & Development, August 2019, Vol.10, No. 8
they know the effects of the disease (treatment, follow-
up, limitations). Functional capacity and quality of
life in patients dependents on any comorbidities, and
this can greatly increase the health care costs of the
comorbidity itself.21coronary artery bypass graft (CABG
This makes the patients feel that their health function has
deteriorated, thereby reducing their quality of life.
Conclusion
Health-related quality of life after CABG has proven
to be significantly improved. The peak time shows that
the patient feels that their quality of life is good after 6
months of action. This needs to be observed again later
on. The link of having many supporters involved in the
improvment of their quality of life is key for the nurses
to control. This is so then the heart patients reduce their
risk of morbidity and mortality.
Ethical Clearance: Ethic clearance was not carried out
or required due to the article being based on a systematic
review.
Source of Funding: There was no funding source in the
research, in the writing of this report or in the decision to
submit the article for publication.
Conflict of Interest: The authors declare that they
have no conflict of interest or financial interest in the
preparation of this article.
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