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Interact CardioVasc Thorac Surg 2008;7:96-101. doi:10.1510/icvts.2007.160382
© 2008 European Association of Cardio-Thoracic Surgery
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Institutional report - Coronary

Gender and physical activity one year after myocardial revascularization for stable angina

Athanasios L.P. Markou, Marijke Evers, Henry A. van Swieten and Luc Noyez*

Department of Cardiothoracic Surgery, Heart Center, Radboud University Nijmegen, 677, PO Box 9101, 6500 HB Nijmegen, The Netherlands

Received 30 May 2007; received in revised form 15 October 2007; accepted 2 November 2007

*Corresponding author. Tel.: +31-24-3613711; fax: +31-24-3540129.

E-mail address: l.noyez{at}thorax.umcn.nl (L. Noyez).


   Abstract
Top
 Abstract
1. Introduction
 2. Patients and methods
 3. Results
 4. Discussion
 5. Conclusion
 References
 
Improvement in physical activity (PA) is an important benefit for patients undergoing CABG. It is suggested that women make less improvement than men. Of 568 patients (466 men and 102 women) undergoing an isolated primary CABG for stable angina (NYHA<4) pre- and 1-year postoperative PA was registered. The Corpus Christi Heart Project criteria are used for assessing PA. The different PA-levels are coded from 1, the worst, to 5, the best. Preoperatively, female patients were older, in a higher NYHA class, and PA level was significantly different and lower 2.30±1.01 vs. 2.89±1.03 (P=0.000). At follow-up, the mean PA increased significantly for women (2.7±1.02) and men (3.2±1.06) (P=0.000). Despite this broad increase, 20% of men and 10% of women had a decreased PA. Multiple logistic regression analysis identified a preoperative high PA-level, diabetes, vascular- and pulmonary disease (odds ratio 7.11, 2.6, 2.3, 2.69) as variables that contribute independently to a worse PA for men and only high preoperative PA level (odds ratio 11.0) for women. This study confirms that patients with a preoperative high level PA are unlikely to improve PA, but in men, diabetes, vascular- and pulmonary disease are also independent risk factors.

Key Words: Physical activity; Myocardial revascularization; Follow-up; Gender


   1. Introduction
Top
 Abstract
 1. Introduction
2. Patients and methods
 3. Results
 4. Discussion
 5. Conclusion
 References
 
Several articles deal with the gender difference in quality of life post myocardial revascularization. Physical activity (PA) is one aspect of quality of life, however, a very important one, certainly for patients undergoing elective CABG for symptom relief. Questions as ‘Doctor, will it be possible to cycle again, or make longer walks after the operation?’ are common during preoperative talks with patients. Literature in this specific field is limited, but it is rather common that women make less improvement in PA post CABG than men [1–7].

The purpose of this study is to evaluate gender difference in PA of patients undergoing CABG for stable angina. Additionally, we analyzed which variables, measured preoperative, contribute independently to worse PA one year postoperative.


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

With the aid of our database, Coronary Surgery Database Radboud Hospital (CORRAD), we identified 568 patients with stable angina (NYHA<4) undergoing a primary isolated myocardial revascularization between January 2002 and December 2004, of which pre- and one-year follow-up registration of quality of life (QOL) using the EuroQol questionnaire, and physical activity, was complete [8, 9].

The total group consisted of 466 men (82%) and 102 females (18%). Table 1 presents the studied pre-, per- and postoperative variables and their definitions. The EuroSCORE was used for risk stratification [10].


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  		Table 1 Variables and definitions

 
2.2. Physical activity

Physical activity is a part of our preoperative QOL registration. For assessing specific PA the criteria of The Corpus Christi Heart Project are used [8]. The five activity levels, their description, and number of patients are presented in Table 2. The levels are coded from 1, the worst, to 5, the best. For logistic regression analysis, preoperatively the levels ≥3 are taken together into a single active group. Postoperative patients were divided into three PA-change groups: patients who improved, did not change, and patients who declined.


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  		Table 2 Activity levels preoperative

 
2.3. Surgical technique

Five hundred and forty-four patients (95.8%) were operated using standard cardiopulmonary bypass technique, aortic and right atrial (two stage) cannulation, hypothermia (28–32 °C) and myocardial protection using St. Thomas' Hospital cardioplegia. Twenty-four patients (4.2%) were operated ‘off-pump’. Because this is only a small amount we did not include ‘off-pump’ as a variable in this study.

2.4. Follow-up

The data result from our yearly-organized follow-up – a written survey directly to the patients. This follow-up is approved by the local ethical and research council and participation in this follow-up is on a voluntary basis [11].

2.5. Statistic analysis

Characteristics of patients are presented as percentage for dichotome variables, and as mean±S.D. and range for numerical variables. Differences in percentages were tested with the {chi}2-test, and numerical variables with the t-test. Student t-tests were performed to analyze the mean differences in PA between both groups. Logistical regression was used to assess the relationship between the PA-change and several preoperative variables. Statistical significance was assumed at P≤0.05 (P=0.000 means P<0.001).


   3. Results
Top
 Abstract
 1. Introduction
 2. Patients and methods
 3. Results
4. Discussion
 5. Conclusion
 References
 
3.1. Patient population

Between January 2002 and December 2004, 1104 myocardial revascularizations were performed. Based on our clinical inclusion criteria, primary isolated and NYHA<4, 861 patients were available for this study. Of 744 patients (86%) preoperative QOL- and/or PA-information was available. During the 1-year follow-up eight patients died and ten patients were lost to or refused follow-up. Of the remaining 726 patients, 158 patients were excluded because of incomplete pre- or postoperative QOL- or PA-information. So the study population consisted of a group of 568 patients, with a mean age of 64.3±9.04 (31–85) years, a mean NYHA class of 2.8±0.38 (1–3), and a mean EuroSCORE of 2.6±2.04 (0–10). The non-included patients had a mean EuroSCORE of 2.6±2.12 (0–9).

3.2. Preoperative data

Sixty-nine women (67.6%) were in the sedentary or minimally active level vs. 179 (38.5%) men (P=0.000) (Table 2). The mean PA for the total group was 2.79±1.05 (1–5), with a significant difference between women, 2.30±1.01 (1–5) and men 2.89±1.03 (1–5) (P=0.000).

The preoperative co-morbidity and cardiac variables (Table 3) show that female patients were significantly older, but further there is no significant difference.


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  		Table 3 Preoperative data

 
Significantly more women were in NYHA III (P=0.043). The mean NYHA-class, however, was not significantly different between female (2.9±0.4) and male (2.8±0.4) (P=0.12).

3.3. Peroperative data

There was no significant difference in the number of grafts, 1.9±0.4 vs. 2.0±0.4 (P=0.42), distal anastomoses; 3.3±1.0 vs. 3.2±1.0 (P=0.59), ECC-time; 85.6±36.7 vs. 82.9±32.2 (P=0.45) and AOX-time; 50.1±22.1 vs. 48.8±32.2 (P=0.40) between both groups. Of all patients, 544 patients (94.2%) received at least one arterial graft.

3.4. Postoperative and follow-up data

Between both groups, postoperative complications, postoperative intensive care stay and hospital stay, attending a rehabilitation program, showed no significant difference (Table 4).


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  		Table 4 Postoperative and follow-up data

 
At one-year follow-up both male and female patients improved in NYHA class. Of the total group, 495 patients (87%) were in a lower NYHA class and 19 patients (3%) in a higher class than preoperatively. The overall mean postoperative NYHA, 1.5±0.79 (1–4) is significantly lower than preoperative (P=0.000). The decrease in mean NYHA class is significant in the male group (1.4±0.7) (1–4), mean change 1.2±0.83, and in the female group (1.6±0.8) mean change 1.2±0.83. There is no statistical difference in the decrease of NYHA class (P=0.35) and mean NYHA class (P=0.15) between male and female. However, there is still a significant difference in NYHA class-distribution between both genders (P=0.003). More female patients are in class NYHA III, 15.2% vs. 6.7% and NYHA II 39.6% vs. 30.4%.

Also in PA registration a significant difference between male and female patients remains (P=0.000). Although the percentage decreased, there are still more female patients in the lowest two physical activity levels than male patients, 46.1% vs. 26.1%.

The overall mean PA increased significantly from 2.7±1.05 preoperatively to 3.2±1.09 after one year with a mean change of 0.50±1.1 (P=0.000). As well for the female group, 2.7±1.02, as for the male group, 3.2±1.06, the one-year postoperative registered PA was significantly better than preoperative (P=0.000 for both groups). However, the increase in PA was not significantly different between male (0.31±1.1) and female (0.47±0.9) (P=0.35).

Evaluating the individual PA-follow-up results to the variables ‘better, equal or worse’ (Table 5), there is a significant difference between the male and female patients (P=0.033), in the male group there were relatively more patients with a worse PA.


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  		Table 5 Change in PA-level, pre- vs. postoperative

 
Table 6 shows that diabetes, vascular-, pulmonary disease and an activity level ≥3 (odds ratio respectively, 2.6, 2.3, 2.6 and 7.11) contribute independently to a worse postoperative PA for male patients. For female patients only the variable activity level ≥3 is significant (odds ratio 11).


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  		Table 6 Multifactor risk analysis (logistic regression) for worse PA post-CABG

 

   4. Discussion
Top
 Abstract
 1. Introduction
 2. Patients and methods
 3. Results
 4. Discussion
5. Conclusion
 References
 
4.1. Patient characteristics

In the study population, we included only patients undergoing myocardial revascularization for stable angina (NYHA<4). First, in these patients the decision to operate can be taken into consideration and eventually patients' expectation concerning postoperative PA is discussed. Second, patients with an NYHA=IV have a greater change to improve there PA, but in the first place due to an improvement of their NYHA class.

Female patients were significantly older than the male. That women tend to be older at the time of operation is common and related to natural history [12].

Although no difference in severity of coronary disease was present, female patients had a higher NYHA and lower PA-registration. Possibly the lower PA level is due to the older age [13]. But several studies confirm that women report greater physical limitation related to stable chronic anginal pain, consistently report worse health than men and have a lower pain tolerance [14].

4.2. Follow-up data

There is a statistical significant decrease of angina for both genders. The mean decrease is not significantly different for male and female patients. However, the significant difference in the NYHA classification persists with less female patients in the NYHA class I. The results of myocardial revascularization on relief of angina are well known and also that women remain more symptomatic compared to men. Women have smaller coronary arteries, which compromise complete revascularization, and result in a higher incidence of early graft failure [12]. Also, there is the sex difference in reporting anginal pain as discussed under the preoperative data.

CABG reduces significantly the limitations of PA for male and female patients. On the other hand, the significant difference in PA-distribution between both genders persists with more women in two lower PA-levels. These results are, broadly speaking, in accordance with studies of Koch et al. [6], Stewart et al. [7] using the Duke Activity Status Index (DASI) for assessing functional status, and Sjöland et al. [5] showing that women start preoperatively at a lower functional level and end at a lower level than men. However, where Stewart confirms our data, concluding that the functional improvement is similar across the genders, the two other studies suggest inferior results in women [5–7].

On the other hand, evaluating the follow-up results to the standard ‘better’, ‘equal’, ‘worse’ shows that only 43% of the patients have an increased PA and 20% a decreased PA. This is in contrast with 87% of the patients in a lower NYHA class. Furthermore, we have a significant difference across both groups. These data are also confirmed by other studies [6, 15]. Stewart categorized the absolute change in DASI score at six months follow-up, for each patient as worse, equal or better, 53% improved, 36% dropped and 11% had no change [6]. Welke et al., using the Short-Form Health Survey (SF-36) report that overall 73.2% of the patients showed improvement in their physical score, and 26.8% a decline, depending on the baseline functional health [15].

Since CABG is performed to improve patients' health we analyzed our data for independent predictors for a decreased postoperative PA. Diabetes, vascular-, pulmonary disease and an activity level ≥3 were identified as independent predictors in male; only activity level ≥3 in female patients. The relevance of the preoperative PA level is confirmed by several studies [5–7, 10, 15]. Diabetes, vascular- and pulmonary disease are also identified in other reports as restrictive on PA [6, 15] – certainly on the higher levels of PA. Probably this is the reason that we identified these variables in only the male group, starting with a higher PA and expecting a higher postoperative PA level.

4.3. Limitations

The first limitation in our study is the small number of patients and the limited follow-up (one year). Also the conversion of physical activity and NYHA into a metric scale can be a point for discussion, however common in this kind of investigation.

But there are other points, only elective, stable patients are included. So our results cannot be generalized for the total population of patients undergoing myocardial revascularization. That female patients are older, speaks only in their advantage. The mean EuroSCORE of the patients not included because of lack of PA or QOL information is the same as for the included patients, which proves that we did not exclude the higher risk patients from this study. The information about postoperative cardiac rehabilitation programs; we only retrieved if patients followed a rehabilitation program, we were not informed about the level of these programs, the result. And at least we did not include ‘event’- information, eventually influencing the PA, at one-year follow-up.


   5. Conclusion
Top
 Abstract
 1. Introduction
 2. Patients and methods
 3. Results
 4. Discussion
 5. Conclusion
References
 
CABG is a good treatment reducing the limitations of PA in patients with stable angina. The increase in mean PA is similar in both genders, however, since women are presented for CABG at a lower PA level, their level remains lower than that of men at one year post CABG.

A clinical consequence of this study is that we must realize that patients with a high PA level preoperatively are unlikely to improve their PA. Additionally, diabetes, vascular- and lung disease are, particularly in men, independent risk factors for a decrease of PA post CABG.


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

  1. Sjöland H, Wiklund I, Caidahl K, Hartford M, Karlsson T, Herlitz J. Improvement in quality of life differs between women and men after coronary artery bypass surgery. J Intern Med 1999; 245:445–454.[CrossRef][Medline]
  2. Vaccarino V, Lin ZQ, Kasl SV, Mattera JA, Roumanis SA, Abramson JL, Krumholz HM. Sex differences in health status after coronary artery bypass surgery. Circulation 2003; 108:2642–2647.[CrossRef][Medline]
  3. Bute BP, Mathew J, Blumenthal JA. Female gender is associated With impaired quality of life 1 year after coronary artery bypass surgery. Psychosom Med 2003; 65:944–951.[Abstract/Free Full Text]
  4. Lindquist R, Dupuis G, Terrin ML, Hoogwerf B, Czajkowski B, Herd JA, Barton FB, Tracy MF, Hunninghake DB, Treat-Jacobson D, Shumaker S, Zyzanski S, Goldenberg I, Knatterud GL. POST CABG Biobehavioral Study Investigators. Comparison of health-related quality-of-life outcomes of men and women after coronary artery bypass surgery through 1 year: findings from the POST CABG Biobehavioral Study. Am Heart J 2003; 146:1038–1044.[CrossRef][Medline]
  5. Sjöland H, Caidahl K, Karlson BW, Karlsson T, Herlitz J. Limitation of physical activity, dyspnea and chest pain before and two years after coronary artery bypass grafting in relation to sex. Int J Cardiol 1997; 61:123–133.[CrossRef][Medline]
  6. Koch CG, Khandwala F, Cywinski JB, Ishwaran H, Estafanous FG, Loop FD, Blackstone EH. Health-related quality of life after coronary artery bypass grafting: a gender analysis using the Duke Activity Status Index. J Thorac Cardiovasc Surg 2004; 128:284–295.[Abstract/Free Full Text]
  7. Stewart RD, Blair JL, Emond CE, Lahey Sj, Levitsky S, Campos CT. Gender and functional outcome after coronary artery bypass. Surgery 1999; 126:184–190.[Medline]
  8. Steffen-Batey L, Nichaman MZ, Goff DC, Frankowski RF, Hanis CL, Ramsey DJ, Labarthe DR. Change in level of physical activity and risk of all-cause mortality or reinfarction. The Corpus Christi Heart Project. Circulation 2000; 102:2204–2209.[Abstract/Free Full Text]
  9. Brooks R. Euro Qol Group. EuroQOL: the current state of play. Health Policy 1996; 37:53–72.[CrossRef][Medline]
  10. Nashef SAM, Roques F, Michel P, Gauducheau E, Lemeshow S, Salamon R. the EuroSCORE study group. European system for cardiac preoperative risk evaluation (EuroSCORE). Eur J Cardiothorac Surg 1999; 16:9–13.[Abstract/Free Full Text]
  11. Wouters CW, Noyez L. Is no news good news? Organized follow-up, an absolute necessity for the evaluation of myocardial revascularization. Eur J Cardiothorac Surg 2004; 26:667–670.[Abstract/Free Full Text]
  12. Cloin ECW, Noyez L. Myocardial revascularization in women: evaluation of hospital mortality and morbidity. Neth Heart J 2006; 14:49–54.
  13. Järvinen O, Saarinen T, Julkunen J, Huhtala H, Tarkka MR. Changes in health-related quality of life and functional capacity following coronary artery bypass graft surgery. Eur J Cardio-thorac Surg 2003; 24:750–756.[Abstract/Free Full Text]
  14. Jackson T, Lezzi T, Chen H, Ebnet S, Eglitis K. Gender. Interpersonal transactions, and the perception of pain: an experimental analysis. J Pain 2005; 6:228–236.[CrossRef][Medline]
  15. Welke KF, Stevens JP, Schults WC, Nelson EC, Beggs VL, Nugent WC. Patient characteristics can predict improvement in functional health after elective coronary artery bypass grafting. Ann Thorac Surg 2003; 75:1849–1855.[Abstract/Free Full Text]

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This Article
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