|Year : 2018 | Volume
| Issue : 4 | Page : 137-143
A pilot study to assess the effectiveness of cardiac rehabilitative teaching program on quality of life and physiological parameters among patients undergoing coronary artery bypass grafting in tertiary care hospital
KP Jyotishana BSc Nursing, 1, Kamlesh Kumari Sharma BSc, MSc, 1, Millind P Hote MCh, 2
1 Department Faculty of Nursing, College of Nursing, AIIMS, New Delhi, India
2 Department of Cardiology, AIIMS, New Delhi, India
|Date of Web Publication||15-Oct-2018|
K P Jyotishana
College of Nursing, AIIMS, New Delhi
Source of Support: None, Conflict of Interest: None
Background: Coronary artery bypass grafting (CABG) is the most common of heart surgeries. Cardiac rehabilitation has been identified as an essential and safer part of care for patients undergoing CABG which eventually would improve quality of life (QOL) and physiological parameters. Objective: The aim of this study is to assess effectiveness of cardiac rehabilitative teaching program (CRTP) on QOL and physiological parameters. Subjects and Methods: A randomized controlled study was undertaken in fifty participants undergoing CABG between June 2016 and January 2017 at tertiary care hospitals. The experimental group received CRTP. The control group received routine teaching. Data were collected at the time of admission, 1 week after discharge, and 2 months after surgery using WHOQOL-BREF questionnaire, activity log sheet, and physiological parameter checklist. Results: The QOL scores of experimental group were significantly higher than the control group, at posttest 1 and posttest 2 in all domains except social domain at posttest 2 (P < 0.05). In both the groups, the QOL scores improved significantly within the group in each domain (P < 0.05) except social domain (P > 0.05). Within the groups, there was a significant improvement in all the physiological parameter scores (P < 0.05) in the experimental group whereas only in heart rate in case of the control group. There was a significant improvement in diastolic blood pressure and hip-waist ratio of experimental group as compared to the control group (P < 0.05). Conclusion: Structured CRTP in CABG patients is effective in improving QOL and to some extent in improving physiological parameters.
Keywords: Cardiac rehabilitative teaching program, coronary artery bypass grafting, physiological parameters, quality of life
|How to cite this article:|
Jyotishana K P, Sharma KK, Hote MP. A pilot study to assess the effectiveness of cardiac rehabilitative teaching program on quality of life and physiological parameters among patients undergoing coronary artery bypass grafting in tertiary care hospital. J Clin Prev Cardiol 2018;7:137-43
|How to cite this URL:|
Jyotishana K P, Sharma KK, Hote MP. A pilot study to assess the effectiveness of cardiac rehabilitative teaching program on quality of life and physiological parameters among patients undergoing coronary artery bypass grafting in tertiary care hospital. J Clin Prev Cardiol [serial online] 2018 [cited 2019 Jun 19];7:137-43. Available from: http://www.jcpconline.org/text.asp?2018/7/4/137/243252
| Introduction|| |
Cardiovascular diseases (CVDs) are the most common health problems and rank first among the causes of death in India. One of the important CVDs is coronary artery disease (CAD) that threatens life.
CVD is the leading global cause of death that accounted for >17.3 million deaths in 2013, a number that is expected to grow to >23.6 million by 2030 also contributing to disabilities, poor quality of life (QOL), and early death.
The incidence of CAD is likely to increase further because of rapid urbanization, lifestyle changes, including changes in diet, physical inactivity, drug and alcohol intake, as well as an increase in the prevalence of diabetes mellitus.
A conservative estimate indicates that there could be 30 million CAD patients in India of which 14 million are in urban and 16 million in rural areas. If the current trend continues by the year 2020, the burden of CAD in India will cross other regions of the world also.
Many of these individuals with CAD have difficulties in resuming a reasonably normal active life including return to work and participation in social and recreational activities. These difficulties result in a poorer QOL for the cardiac patient. Nowadays, it is documented that participation in cardiac rehabilitation (CR) has a positive effect on QOL.
CR has been identified as an essential, useful, and safe part of the care for patients with CAD. Interventions such as management of hypertension, smoking cessation, and CR may help the patients to obtain the highest level of physical health and QOL.
After coronary artery bypass grafting (CABG), national guidelines strongly recommend CR for all patients. Improving QOL is one of the important goals of patients for participating in CR program.
As a fundamental part of every CR, regular physical activity can improve functional work capacity in cardiac patients after CABG. Regular physical activity enhances hemodynamic responses such as resting and maximum systolic blood pressure (BP), diastolic BP, and heart rate (HR).
CR evolved over the past decades from a simple monitoring to physical activities to a multidisciplinary approach for the safe return that focuses on patient education, individually tailored exercise training, modification of the risk factors, and the overall well-being of the cardiac patients. It has been proven to be an effective tool for the care of the patients with heart disease.
As the population ages and surgical technologies improve, the number of individuals undergoing CABG surgery will continue to rise. Hence, it is important for health-care providers to structure appropriate and easy cardiac rehabilitative teaching program (CRTP) for this growing population.
| Subjects and Methods|| |
This randomized controlled trial was conducted at a tertiary care hospital, cardiology department, New Delhi, from June 2016 to January 2017, among randomly chosen fifty participants who had undergone elective CABG. The sample size was calculated based on pilot study findings, keeping type I error as 0.05 and type II as 0.2 and with a 5% level of significance. The calculated sample size was 22 (11 in each group), and considering 10% of dropout rate, 25 patients were estimated to be the sample in each group. Total sample size included for the study is 50 (25 in each group).
The study population included the patients of all ages, who were posted for elective CABG, willing to participate, and give informed consent for the study and who could read and communicate in Hindi/English. Patients who are unable to follow commands having left ventricular ejection fraction <30% or with other documented cardiac comorbidities such as valve replacement surgery, dysrhythmias, heart transplants, or implanted with either cardiac resynchronization therapy or implantable cardioverter-defibrillators were excluded from the study.
Patients meeting the inclusion criteria were enrolled in the study and informed written consent was obtained. They were randomly assigned into either of the groups (experiment and control) using computer-generated random number table. Both the groups received routine teaching while the experimental group also received the CRTP under privacy. The CONSORT diagram depicting the study design is presented in [Figure 1].
CRTP used in this study refers to systematically planned teaching program for patients undergoing elective CABG surgery; designed to provide information about anatomy of the heart, CABG surgery, various treatment modalities, type of grafts used in CABG, expectations after CABG surgery, care of incision site and sternum, nutrition, exercise program, sexual life, risk modification strategy, and follow-up using self-developed booklet, lecture (power point presentation) cum demonstration method through one-to-one teaching.
- CRTP was self-developed structured booklet both in English and Hindi language. Review of literature was also done in order to collect information regarding the topic. Content was developed with the help of the opinion of experts and was validated by six clinical experts. The recommendations and suggestions of the experts were taken into consideration while preparing the content of the CRTP. Competency to teach CRTP exercises to the participants was certified by physiotherapist. This program comprises seven components: (1) introduction to CABG, (2) expectation after surgery, (3) care of incision, (4) exercise program, (5) nutrition, (6) sexual life, and (7) risk modification strategy and follow-up [Figure 2]
- CRTP was administered in three parts: (a)First part was administered on the day of admission and it included knowledge about anatomy of heart, CAD, various treatment modalities, CABG and choice of grafts, expectations after surgery, exercise program, and importance of CR. One-to-one individual teaching and demonstration of exercises were done for 30 min. (b) Second part administered on the 3rd or 4th postoperative day and included care of incision site, care of sternum, sign of incision infection, and reinforcement of exercise program. Total time taken for this section was about 20 min. Doubts were cleared immediately after teaching. (c) Third part administered on the day of discharge included nutrition, sexual life, risk modification strategy, follow-up, and reinforcement of exercise program. Total time duration for this section was about 20 min. Doubts were cleared immediately after teaching.
In order to ensure the consistency and regular implementation of the CRTP at home, the participants in experimental group were given an activity log sheet to be filled on daily basis by them. Telephonic reinforcement was done every Monday (9 a.m. to 5 p.m.) for 2 months of duration. During this call, patients were asked a few questions regarding their health condition and clarified doubts of participants if any and reinforcement was done regarding CRTP and maintaining of the log sheet. Then, baseline sociodemographic profiles were collected using the structured self-developed questionnaire.
Experimental group was followed up 1 week and 2 months after the surgery with weekly telephonic reinforcement whereas control group was directly posttested at 1 week and 2 months after the surgery.
The study was approved by the Institute Ethics Committee for Postgraduate Research. Informed consent was obtained from the participants before enrollment in the study.
The analysis was performed using STATA 14 version (StataCorp) and SPSS 19 (Armonk, NY: IBM Corp). Descriptive statistics (mean, standard deviation, percentage, and frequency) were used to describe sociodemographic profile. Inferential statistics, including repeated measures ANOVA followed by Bonferroni multiple comparison tests and Wilcoxon signed-rank test, was used to compare change over a period of time within group. Independent t-test and Mann–Whitney test was used to compare the scores between the groups. Chi-square and Fisher's exact test was used to find association between categorical variables. The level of significance was considered as P < 0.05.
| Results|| |
This study was done among 50 patients, who had undergone elective CABG. There was a loss to follow-up of two participants in each group; hence, 23 patients (23 in each group) were included in the study. The mean age of the study was 60 ± 8.3 in experimental and 57.8 ± 9.0 in the control group. Majority of the participants in either group were males. Most of the experimental group participants belonged to rural community (64%) whereas control group belonged to urban community (52%). Majority of the participants in either group were illiterate. Both groups were comparable in terms of demographic profile, i.e., age, gender, area of living, education level, hours of work done per day, dietary habits, religion, monthly income, smoking habits, hypertension, and diabetes mellitus except alcohol consumption habit (P = 0.025) [Table 1].
Quality of life
A statistically significant improvement was observed within both the groups in terms of physical (P = 0.001, 0.001), psychological (P = 0.001, 0.001), and environmental domain (P = 0.001, 0.03) except social domain (P = 0.29, 0.34) in experimental and control group, respectively. The mean scores of all domains of QOL were significantly higher in the experimental group depicting better QOL than the control group [Table 2].
|Table 2: Comparison of mean quality of life scores between and within study groups at baseline and after administration of cardiac rehabilitative teaching program in coronary artery bypass grafting participants (n=50)|
Click here to view
An ongoing statistically significant improvement was observed within the groups in the mean scores of overall QOL (P = 0.001, 0.001) and general health scores (P = 0.001, 0.001) in experimental and control group, respectively. Further significantly improved mean scores were also observed in experimental group as compared to control group at 1 week (P < 0.05) and 2 month after intervention (P < 0.05) in both overall QOL and general health [Table 3].
|Table 3: Comparison of mean overall quality of life and general health score between and within study groups at baseline and after administration of cardiac rehabilitative teaching program in coronary artery bypass grafting participants (n=50)|
Click here to view
A statistically significant improvement in all physiological parameters, i.e., body mass index (BMI, P = 0.001), systolic BP (P = 0.001), diastolic BP (P = 0.006), HR (P = 0.03), and hip-waist ratio (HWR) (P = 0.01) was observed within the experimental group. On the other hand, a statistically significant improvement only in HR (P = 0.02) was observed within the control group. In addition, a significant shift toward normal range was noted in the diastolic BP (P < 0.05) and HWR (P = 0.05) of experimental group as compared to control group after CRTP. However, no statistical significant difference was found between the groups in other physiological parameters (diastolic BP, systolic BP, and HR) [Table 4].
|Table 4: Comparison of physiological parameters between and within study group at baseline and after administration of cardiac rehabilitative teaching program in coronary artery bypass grafting participants (n=50)|
Click here to view
The trends of changes in physiological parameters
Body mass index
There was a drop in BMI in experimental group from pretest to posttest 1 (P = 0.03) and also in control group (P = 0.07). However, BMI returned to desired level at 2 months after CRTP in the experimental group from pretest to posttest 2 (P = 0.001). Thus, BMI between both groups was within normal range but with no statistically significant difference (P > 0.05).
Systolic blood pressure: In experimental group, there was significant decrease in systolic BP after CRTP (P = 0.001), whereas in control group, no significant difference was found (P > 0.05). However, between the groups, no significant difference was found.
Diastolic blood pressure
In experimental group, there was significant decrease in diastolic BP after CRTP (P = 0.006) but not in the control group (P = 0.76). However, at posttest 2, the experimental group moved to normal range and control group shifted to prehypertension stage. Further, a significantly bigger shift toward normal range was noted in the diastolic BP of experimental group (P < 0.05) as compared to control group (P > 0.05).
In experimental group, there was a significant decrease in HR from posttest 1 to posttest 2 (P = 0.031) to desired level of HR after CRTP. A significant improvement in HR (P = 0.02) was observed within control group. However, no significant difference in HR was found between the groups.
The high-risk participants were more in the experimental group 12 (48%) than control group 11 (44%) at pretest, but this difference was not statistically significant (P > 0.05). After CRTP, there was a significant decrease in high-risk group participants in the experimental group (P = 0.04) than the control group (P = 0.24) and also significant decrease in BMI toward the normal range observed from pretest to posttest 2 (P = 0.01) in experimental group, but no significant difference was observed in control group. There was statistically significant shift in HWR from high-risk category to moderate-risk category within the experimental group both from posttest 1 to posttest 2 and pretest to posttest 2. [Table 5] shows the comparison of HWR between and within study groups.
|Table 5: Comparison of hip-waist ratio between and within study groups (n=50)|
Click here to view
| Discussion|| |
Our study revealed that CRTP was significantly effective in improving QOL and to some extent also the physiological parameters too.
Quality of life
This study demonstrated the significant improvement in the mean QOL score in terms of all domains except social domain within both the groups. The mean QOL scores were significantly higher in experimental group than control group after CRTP. These findings are also supported by other studies.
Alahyari et al. also reported that positive effects of rehabilitation on the scores of all domains of QOL were significantly higher in experimental group than the control group except for the scores of social functioning, bodily pain, and role limitations, and the scores of other domains of QOL increased significantly in the control group which is consistent with the present study.
Salavati et al. reported significant increase in the mean score of health-related QOL in both groups 2 months after CR program, but this increase in patients in Group II (who received CR programs) was higher than patients in Group I (usual care). The significant difference observed in all three subscales (P > 0.05) in both the groups. Meanwhile, mean score of social domains significantly decreases in control group in the present study probably because of the fear of having heart attack again after surgery.
Mark et al. conducted retrospective, one-group study on the medical files of 100 cardiac patients that demonstrate improvement of patients' QOL (P < 0.05) after CR. The study of Attarbashi-Moghadam et al. showed that an improvement in all domains of SF-36 questionnaire (P < 0.005) after CR before and after the program and at 3-month follow-up among 44 patients. In the present study, the length of monitoring was only 2 months. However, the present study findings are not supported by Tavella and Beltrame who reported that by 6 months, all patients showed an improvement in QOL domain scores; however, the rate of improvement did not differ between the controls and CR participants.
In the present study, significant increases in the scores of QOL mean domains in the control group may be due to patients' increased awareness and curiosity to know for better improvement of QOL after CABG. Furthermore, participants sensitized to QOL at pretest and posttest 1, and hence, they tried to get more information from hospital staff and Internet in order to improve their QOL than previous QOL.
In the present study, statistically significant improvement was observed in diastolic BP and HWR in experimental group compared to control group. However, no significant improvement in BMI, systolic BP, and HR observed between the groups though a significant improvement was found within the experimental group.
Thapa and Pattanshetty in their prospective study among fifty patients reported statistically significant difference in systolic BP (P = 0.018) and HR (P ≤ 0.001) but not in diastolic BP, whereas in the present study, statistically significant improvement was observed in diastolic BP and HWR too after CRTP within experimental group.
Nalini et al. where they reported significantly decreased waist-to-hip ratio and BMI with 2-month supervised CR program in 167 participants. All of measurements relatively returned to pretest at the end of program (after 12 months). However, the present study was conducted on fifty elective coronary bypass surgery patients.
The strengths of the present study are that it is a randomized controlled trial. Furthermore, CRTP was simple to administer and easily understood by the patients. Implications of this study are (1) CRTP can be operationalized in cardiology wards and outpatient department for CABG patients. (2) Students and nursing staff should be trained and encouraged to implement CRTP for CABG patients. (3) Further research may be conducted on the use of CRTP with a large sample size, in a multicentered setting with different cardiac patients groups. (4) Nurse should be encouraged to practice CRTP and stress on creating awareness among patients about CABG surgery, care of incision site, exercises, and importance of follow-up. The long-term effect of CRTP can be assessed in the longitudinal study, or a similar study can be replicated with different groups of cardiac patients.
The study was small sample size and a single-center study which limits the generalizability of the study. Long-term effect of CRTP was also not studied and there are chances of sample contamination due to exchange of information between the participants in both groups. The participants may have personal differences that can alter their QOL and which are out of researcher's control.
| Conclusion|| |
The structured CRTP in CABG patients was effective in improving the QOL significantly and also improving the physiological parameters to some extent. Moreover, it is easy to implement and understandable by cardiac patients. This provides a ray of hope for the ever-increasing number of patients undergoing CABG. Nurses can play a critical role in implementing CRTP for patients after CABG.
The authors would like to thank WHOQOL-BREF questionnaire author for permitting permission to use the tools in the study.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
Bhatnagar P, Wickramasinghe K, Williams J, Rayner M, Townsend N. The epidemiology of cardiovascular disease in the UK 2014. Heart 2015;101:1182-9.
Benjamin EJ, Blaha MJ, Chiuve SE, Cushman M, Das SR, Deo R, et al.
Heart disease and stroke statistics-2017 update: A report from the American Heart Association. Circulation 2017;135:e146-603.
Sekhri T, Kanwar RS, Wilfred R, Chugh P, Chhillar M, Aggarwal R, et al.
Prevalence of risk factors for coronary artery disease in an urban Indian population. BMJ Open 2014;4:e005346.
Reddy KS, Yusuf S. Emerging epidemic of cardiovascular disease in developing countries. Circulation 1998;97:596-601.
Antonakoudis H, Kifnidis K, Andreadis A, Fluda E, Konti Z, Papagianis N, et al.
Cardiac rehabilitation effects on quality of life in patients after acute myocardial infarction. Hippokratia 2006;10:176-81.
McKee G. Are there meaningful longitudinal changes in health related quality of life – SF36, in cardiac rehabilitation patients? Eur J Cardiovasc Nurs 2009;8:40-7.
Kulik A, Ruel M, Jneid H, Ferguson TB, Hiratzka LF, Ikonomidis JS, et al.
Secondary prevention after coronary artery bypass graft surgery: A scientific statement from the American Heart Association. Circulation 2015;131:927-64.
Pack QR, Goel K, Lahr BD, Greason KL, Squires RW, Lopez-Jimenez F, et al
. Participation in cardiac rehabilitation and survival after coronary artery bypass graft surgery clinical perspective. Circulation 2013;128:590-7.
Baldassarre FG, Arthur HM, Dicenso A, Guyatt G. Effect of coronary artery bypass graft surgery on older women's health-related quality of life. Heart Lung 2002;31:421-31.
Mampuya WM. Cardiac rehabilitation past, present and future: An overview. Cardiovasc Diagn Ther 2012;2:38-49.
Alahyari E, Izadpanah AM, Sharifzadeh G, Moghadam HR. The effects of phase III cardiac rehabilitation on the quality of life of patients undergoing coronary artery bypass graft. Mod Care J 2015;12:e8665. doi: 10.17795 Available from: http://www.mcjbums.com/en/articles/8665.html
. [Last accessed on 2017 Feb 07].
Salavati M, Fallahinia G, Vardanjani AE, Rafiei H, Mousavi S, Torkamani M. Comparison between effects of home based cardiac rehabilitation programs versus usual care on the patients' health related quality of life after coronary artery bypass graft. Glob J Health Sci 2015;8:196-202.
Mark DB, Knight JD, Velazquez EJ, Wasilewski J, Howlett JG, Smith PK, et al.
Quality-of-life outcomes with coronary artery bypass graft surgery in ischemic left ventricular dysfunction: A randomized trial. Ann Intern Med 2014;161:392-9.
Attarbashi-Moghadam B, Hadian M, Baqeri H, Tavakol K, Salarifar M, Jalaie S, et al
. The effects of phase II cardiac rehabilitation on quality of life scales in post coronary artery bypass grafts patients. Mod Rehabil 2014;12:12-8.
Tavella R, Beltrame JF. Cardiac rehabilitation may not provide a quality of life benefit in coronary artery disease patients. BMC Health Serv Res 2012;12:406.
Thapa S, Pattanshetty RB. Effect of chair aerobics as low intensity exercise training on heart rate, blood pressure and six minute walk distance in post coronary artery bypass graft surgery patients through phase I cardiac rehabilitation. Nepal Heart J 2016;13:19-23.
Nalini M, Moradi B, Esmaeilzadeh M, Maleki M. Does the effect of supervised cardiac rehabilitation programs on body fat distribution remained long time? J Cardiovasc Thorac Res 2013;5:133-8.
[Figure 1], [Figure 2]
[Table 1], [Table 2], [Table 3], [Table 4], [Table 5]