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Diet and Exercise Interventions Following


Coronary Artery Bypass Graft Surgery: A Review
and Call to Action

Garrett N. Coyan MSc, K. M. Reeder PhD, RN & James L. Vacek MD, MSc

To cite this article: Garrett N. Coyan MSc, K. M. Reeder PhD, RN & James L. Vacek MD, MSc
(2014) Diet and Exercise Interventions Following Coronary Artery Bypass Graft Surgery: A
Review and Call to Action, The Physician and Sportsmedicine, 42:2, 119-129

To link to this article: http://dx.doi.org/10.3810/psm.2014.05.2064

Published online: 13 Mar 2015.

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C L I N I C A L F E AT U R E S

Diet and Exercise Interventions Following


Coronary Artery Bypass Graft Surgery: A Review
and Call to Action

DOI: 10.3810/psm.2014.05.2064
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Abstract: Coronary artery bypass graft (CABG) surgery has been used for the treatment of
coronary artery disease (CAD) for approximately 50 years, and has been performed on millions
Garrett N. Coyan, MSc 1 of people globally. However, little is known about the impact of diet and exercise on long-term
K. M. Reeder, PhD, RN 2 outcomes of patients who have undergone CABG surgery. Although clinical practice guidelines
James L. Vacek, MD, MSc 1,3 on the management of this patient population have been available for approximately 2 decades,
1
University of Kansas Medical Center, evidence regarding secondary prevention behavioral interventions, lifestyle modifications and
Kansas City, KS; 2Goldfard School of self-management to slow the progressive decline of CAD, reduce cardiac hospitalizations, and
Nursing at Barnes-Jewish College,
St. Louis, MO; 3Mid-America prevent reoperation remains virtually absent from the literature. Diet and exercise are modifiable
Cardiology, Kansas City, KS factors that affect secondary CAD risk. This article reviews the relevant current literature on
long-term diet and exercise outcomes in patients who underwent CABG. The limited available
literature shows the positive impacts of exercise on psychosocial well-being and physical fit-
ness. Current evidence indicates diet and exercise interventions are effective in the short-term,
but effects fade over time. Potential age and sex differences were found across the reviewed
studies; however, further research is needed with more rigorous designs to replicate and confirm
findings, and to define optimal management regimens and cost-effective prevention strategies.
Keywords: CABG; diet; exercise; long-term outcomes; physical activity; nutrition

Introduction
Coronary artery bypass graft (CABG) surgery is a reliable treatment option for patients
with coronary artery disease (CAD) not amenable to medical management or percu-
taneous coronary intervention (PCI).1 In 2010, an estimated 219 000 CABG surgeries
were performed in the United States alone.2 As more patients undergo this surgical
procedure and short-term outcomes continue to improve, the number of long-term
survivors will increase. Consensus guidelines to limit CAD progression and maintain
positive outcomes of CABG are urgently needed for this substantial patient population.3
Although national guidelines for optimizing medical management of postoperative
CABG surgical patients have been published, most of the evidence focuses on medi-
cation adherence and tobacco cessation.3,4
Little evidence exists regarding the long-term (. 1 year) impact of lifestyle changes,
Correspondence: Garrett N. Coyan, MSc,
University of Kansas Medical Center, such as diet and exercise, on outcomes in patients who underwent CABG57; diet and
3901 Rainbow Blvd, Mailstop 4023, exercise, if included in studies, are usually measured as secondary endpoints.8 Poor
Kansas City, KS 66160.
Tel: 316-461-9040
diet and lack of exercise are known risk factors for the subsequent development and
E-mail: gcoyan@kumc.edu worsening of CAD in patients post-CABG, and recent studies suggest that the lack of

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Coyan etal

a healthy diet and exercise remain important risk factors in must be included); 2) long-term ($12months) follow-up
this patient population.9,10 Considering this evidence, little must be reported, even if the exercise or diet intervention
is known about the long-term impact of diet and exercise lasted,1 year; 3) articles must have used diet or exercise as
interventions in patients post-CABG surgery.11 This review independent variables in the research question and analysis;
of the recent literature was conducted to synthesize extant 4) outcomes included (broadly) functional status, psychoso-
research, highlight gaps in knowledge, and identify further cial status, symptom status, exercise capacity, and adverse
areas of research on diet and exercise post-CABG surgery. cardiac events; 5) available in English; and 6) published
This article illustrates the need for a renewed vigor in between January 1995 and May 2013. Outcome measures
researching optimal management paradigms for patients were intentionally left broad because of the small number of
post-CABG in terms of diet and exercise intervention. With available studies. All types of study designs were represented
changes in the delivery of health care in the United States in the final review.
and abroad, developing evidence-based guidelines for this
population is of the utmost importance. Summary
Based on a priori inclusion criteria, a total of 9 articles were
Materials and Methods determined to be relevant for inclusion (Figure1). Of the 9
A literature search was conducted using 4 electronic data- published studies, 1 addressed long-term diet outcomes, 5
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bases: Medline (accessed through PubMed), Cochrane examined the impact of long-term exercise, and 3 examined
Database of Systematic Reviews, Cochrane Central Reg- the impact of both diet and exercise interventions on long-term
ister of Controlled Trials, and CINAHL (Cumulative Index post-CABG outcomes (Table1); 2 were randomized clinical
to Nursing and Allied Health Literature). Search terms trials and 7 were observational (nonintervention or cohort)
used to identify pertinent articles from the databases were studies addressing long-term outcomes in patients post-CABG.
CABG and coronary artery bypass surgery in combination As expected, reporting of various outcomes was inconsistent
with diet, nutrition, exercise, and physical activity. Articles across studies, precluding meta-analysis feasibility.
published in English between 1995 and 2013 were retrieved
and evaluated for relevance to the topic using the stated Diet Alone
criteria. References cited in those articles were also culled Surprisingly, few studies specifically examining the effects
for additional studies. of dietary interventions in the post-CABG surgery population
The goal of our search was to identify long-term out- have been published. A small cohort study on dietary habits,
comes in patients post-CABG. Long-term outcomes were including preoperative and postoperative dietary advice, was
defined as having $1 year of follow-up included in the conducted with 15men post-CABG.13 During the 1-year
study, consistent with previous reviews on exercise outcomes follow-up period, investigators found that total fat, saturated
in patients with CAD12; in this review, short-term outcome fat, and dietary cholesterol significantly increased from pre-
was used to describe follow-up time,12months. Because operative total fat, saturated fat, and dietary cholesterol daily
we were aware that few studies were published that examin- intake reports (21%, 36%, and 51%, respectively; P,0.05),
ing the long-term outcomes of diet and exercise in patients which is remarkable because the patients had just undergone
who underwent CABG, cohort studies, case-control studies, a major surgical procedure. Although the sample was small,
cross-sectional study designs, and randomized clinical trials findings indicated the need for long-term monitoring of self-
were included. Therefore, a meta-analysis was not planned management components, such as diet, by both clinicians and
because we expected to find differing endpoints. patients. Further research is needed to examine long-term
Titles and abstracts were reviewed based on results diet self-management in large samples of both sexes post-
of the queries previously described. Complete articles CABG surgery. Dietary modifications are essentially risk free
were retrieved and reviewed if the abstracts listed patients and relatively inexpensive secondary preventive strategies
with CABG in the study population, reported $1 year of compared with pharmacologic therapies, and require further
follow-up, and evaluated diet or exercise in some manner. investigation and implementation if found to be effective.
Articles were selected for final inclusion in the review if
the following criteria were met: 1) patients included in the Exercise Alone
study underwent CABG surgery (if mixed cohort study, Short-term outcomes of cardiac rehabilitation (CR) have
$50% must have received CABG and subgroup analysis been studied extensively in the CABG patient population;

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Diet and Exercise Interventions Post-CABG

Figure1. Literature review search flow diagram based on a priori inclusion exercised.2 times each week (P,0.01). The same group
criteria.
of non-exercising women had statistically lower physical
and social functional status outcomes than all categories of
men (P,0.01). The study found that men were more likely
to engage in exercise and exercised at a higher intensity in
all age groups compared with women (P,0.01). Women
aged .65 years were shown to be especially at risk in
this study, having significantly lower physical and social
functional status scores than all other study participants
(P,0.01). Because this study had a significant oversampling
of women compared with other studies reviewed, it uniquely
represented exercise outcomes in women with CAD post-
CABG surgery. The data demonstrate overall that increased
exercise is associated with improved long-term physical
and social functional status outcomes post-CABG in both
sexes. There were also trends for decreased frequency and
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intensity of exercise in women, but patients who did exercise


experienced improved outcomes.
In a separate analysis of the same post-CABG cohort,
moderate exercise was associated with reduced shortness
of breath (P =0.01) and fatigue (P ,0.001). A decrease
in anginal chest pain was seen in those who exercised but
however, few studies on long-term outcomes of exercise the decrease was not significant (P =0.07).16 Notably, a
beyond initial CR programs were found in the literature small number of patients reported angina throughout the
search. One study providing long-term outcome data on exer- observational study period, perhaps making differences in
cise was the Minnesota arm of the Post CABG Biobehavioral angina secondary to exercise especially difficult to detect.
Study.14 Investigators analyzed data that focused on the effect In addition, significant increases in QOL were reported by
of exercise on functional outcomes, symptoms, and quality patients who exercised compared with those who did not
of life (QOL) in patients 5 to 6 years post-CABG.15,16 This (P=0.05).
study was an observational, nonintervention study of patients A possible major limitation of this observational study
long-term exercise habits after CABG. Of the original 200 was recall bias introduced in years 5 through 6 of follow-up;
participants, 184surviving patients (105men and 79 women) because self-report of activity and symptoms were used, this
were contacted for the study, with 163 participating in the study may have been particularly vulnerable to recall bias.
study. In this secondary analysis study, a multivariate model Additionally, there was no comparison group and no active
controlling for age, sex, severity of angina, shortness of intervention took place in this study. Conversely, several
breath, and fatigue showed that higher levels of exercise were strengths of this study are important to note. This study
associated with increased functional status, as measured by included a long length of follow-up time, and the amount
the validated Functional Status Questionnaire (P,0.01).15 of data provided by participants was fairly complete despite
In this study, regular exercise, including low to moderate the long follow-up period. Additionally, the surveys used in
levels of exercise, was associated with improved functional this study were previously verified and are known to pro-
status. This finding suggests that even low levels of exercise vide robust results. These studies are especially important
in patients who have undergone CABG surgery may benefit in regard to long-term outcomes for women because this
functional status, which is important for preventing progres- study contained a substantial number of women, making
sive worsening of CAD, maintaining independence, and comparisons between men and women more useful than in
avoiding hospitalizations. Significant differences between other studies where women comprised,30% of the sample
men and women were also found. Women who did not exer- population. Prospective trials using a structured, monitored
cise.2 times a week had significantly lower physical and intervention setting are needed to further test the associations
social functional status outcomes compared with women who found in this study.

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Table 1. Effect of Diet and Exercise on Post-CABG Outcomes


Author Study Aim Patients Methods Principal Findings Quality Conclusions
(Study Name)
Coyan etal

122
Diet Alone
Hartwell and Assess the effectiveness 15 men Observational prospective cohort; Total fat, saturated fat, and cholesterol all Small, low-powered study; Further research is needed to
Henry,13 2003 of dietary advice to food frequency questionnaire increased during the year of follow-up no rigorous intervention; understand barriers to proper
patients with CABG was used to evaluate diet follow-up and completion of diet in patients post-CABG
preoperatively, 2 months questionnaire was good
postoperatively, and 1 year post-
CABG; patients received standard
dietary counseling pre- and
postoperatively
Exercise Alone
Treat-Jacobson and Compare exercise 163 men and Observational prospective cohort Women had lower physical and social Large study design with high Exercise is related to better
Lindquist,15 2004 behavior vs functional womena followed via phone interview and functioning scores; men were more likely participation rate; higher than functional outcomes 56 years
(Post CABG status outcomes in men self-administered questionnaires to exercise regularly. Exercisers had average percent of women in post-CABG
Biobehavioral Study) and women 56 years higher functional scores than the study; no control group
post-CABG nonexercisers or specific intervention
Treat-Jacobson and Compare exercise 163 men and Observational prospective cohort Regular exercise and increased Large study design with high Exercise is related to increased
Lindquist,16 2007 behavior, functional womena followed via phone interview and functional status scores associated with participation rate; higher than QOL and greater symptom
status, symptoms, self-administered questionnaires decreased shortness of breath and average percent of women in control in the CABG
and QOL in men and fatigue, increased perception of health, the study; no control group population
women 56 years and increased QOL measures or specific intervention
post-CABG
Martini and Determine the effect 202 men and Observational prospective cohort LTPA decreased from pre- to Study was underpowered to LTPA does not significantly
Barbisan,17 2010 of LTPA on long-term women comparing MACE and functional postoperative time period; there were detect significant differences impact MACE during 2 year
prognosis 2 years status outcomes between less MACEs in the active group (P = NS); in MACE; validated follow-up; increased activity
post-CABG sedentary and active groups of increased LTPA was associated with questionnaires used to is associated with improved
LTPA improved functional status measure LTPA and outcomes; functional outcomes in this
no regression model same time interval
constructed
Oldenburg et al,18 Evaluate the efficacy 86 men and Randomized clinical trial; Few differences in risk factors developed Medium sized randomized Modest success with
1995 of CR programs in women intervention group meets weekly between groups; major difference was trial, with many metrics intervention may point to
patients with CABG for 6 weeks, with periodic increased aerobic capacity and exercise measured; generalizability of unexplored differences in the
in terms of risk factor booster sessions aimed at lifestyle adherence in the intervention group; all such intense meetings may CABG population from other
modification, QOL, and modifications patients experienced increased QOL be difficult cardiac patients; increased
symptom control aerobic activity observed
is beneficial for long-term
symptom reduction

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Smith et al,19 2004 Examine sustainability 198 men and Randomized clinical trial Vo2max declined in the hospital-based Relatively large randomized Patients who receive CR
of physical activity, women examining outcomes 12 months group, but uptake was retained in the trial, with good long-term in-home post-CABG may have
QOL, and social after a 6-month CR program home group. Physical QOL was higher follow-up and retention; increased physical activity and
support in patients completed either in-home in the home vs hospital CR group, various outcomes are QOL 12 months post-CR
12 months after or in-hospital (randomized but mental QOL was similar between compared between groups.
in-hospital or in-home allocation); outcomes included groups; patients receiving home-based Good generalizability to
CR post-CABG Vo2 max, QOL, physical activity, and CR had higher physical activity scores low-risk population; however,
social support after 12 months medium- and high-risk
populations not studied
Diet and Exercise
Vachenauer et al,20 Evaluate lifestyle 2269 men and Retrospective observational Desire for nutritional counseling and Large powered study, diverse
Attention to nutrition
2008 modifications post- women survey during a 10-year period dietary habit change decreased over patient population followed
deteriorated over time;
CABG and correlate collecting lifestyle modification time; fewer men than women adhered over long-term; no actual
patients would benefit
these changes to data by questionnaires # 5 years to dietary guidelines and fewer women intervention tested
from dietary education and
freedom from post-CABG adhered to exercise guidelines; notable increased physical activity,
symptoms differences across various age ranges in especially in select sex and age
these categories as well. Patients with groups shown to be at risk.
recurrent symptoms were more likely to Patients should be encouraged
seek out and follow dietary advice to follow recommendations
before symptom recurrence
Griffo et al,11 2013 Determine the impact 1262 men and Observational prospective cohort 72% of patients adhered to diet, Multicenter, high-power CR is a reliable treatment
of CR program on women (69% design following consecutive while only 51% adhered to exercise study with detailed long-term option for patients undergoing
lifestyle modifications underwent revascularization patients recommendations. Sedentary lifestyle follow-up; several metrics CABG with lifestyle
and predictors of poor CABG) through a comprehensive CR before the event was associated with measured; mixed cohort modifications and medication
behavioral change post- program; risk factors, habits, and poor dietary habits, while older patients (not exclusively patients with adherence; further research is
CABG or PCI medications were monitored with comorbidities were more likely CABG) needed on those behavioral
through 1 year to discontinue most therapies and diet characteristics found to be
recommendations; medication adherence counterproductive
was higher than lifestyle modification
adherence
Lee et al,21 2009 Identify the 109 men and Observational prospective Increased exercise and physical activity Small observational cohort, Physical activity is associated
determinants of women cohort study using a face-to-face associated with increased physical with complete patient with increased physical QOL,
physical and mental interview 5 years postsurgery to health-related QOL; proper diet data; physical activity while diet is associated with
QOL 5 years post- determine QOL using the SF-36; (measured by increased score) was was measured using a mental QOL in CABG patients

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CABG surgery various risk factor scores were found to be related to increasing mental nonvalidated form.Validated 5 years postsurgery; further
used as independent variables in health-related QOL measures were used for studies are needed to clarify
a hierarchal regression analysis to QOL and diet; specifics of possible causal relationships
find associations with physical and the regression were not with updated validated
mental QOL scores included measurement tools
a
The same cohort was used in both studies by Terry-Jacobson and Lindquist.
Abbreviations: CABG, coronary artery bypass graft; CR, cardiac rehabilitation; LTPA, leisure-time physical activity; MACE, major adverse cardiac event; NS, not significant; PCI, percutaneous coronary intervention; QOL, quality of life;
SF-36, Short Form 36 survey;Vo2max, peak oxygen consumption.

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Diet and Exercise Interventions Post-CABG
Coyan etal

The effect of leisure-time physical activity (LTPA) on determine the effect of LTPA on major cardiac events because
long-term outcomes 2 years post-CABG was studied by this study was underpowered to detect such changes.
Martini and Barbisan.17 In this observational cohort study, Oldenburg etal18 conducted a randomized clinical trial
patients were classified as being active (those involved in to examine the effect of an exercise and behavioral inter-
physical activity $3 times a week for $20minutes in the last vention program on long-term outcomes in 86 patients who
2 weeks) and sedentary (anything less than active) according to underwent CABG. The intervention consisted of 6 weekly
LTPA. Patients were also provided the Baecke Questionnaire group meetings beginning at 4 to 8 weeks postoperatively and
of Habitual Physical Activity to confirm active versus seden- with follow-up meetings at 8months and 1 year. The weekly
tary physical activity status. The primary outcome of interest group meetings focused on components of self-management,
was major adverse cardiac events (death, hospital readmis- including lifestyle modifications for diet and exercise. The
sion, cerebrovascular accident, and myocardial infarction), meetings were structured for group discussions on selected
with secondary outcomes of functional status measured by topics with an expert group facilitator. In addition, individual
the 6-minute walk test and the Veterans Specific Activity risk reduction plans were developed, progress was discussed,
Questionnaire. Of the 202 patients enrolled, 66 (33%) were and patients were coached during subsequent meetings. An
considered active and 136 were considered sedentary (67%). exercise program focused on gradual increases in activity
The only significant difference between the cohort was sex, (enough to break a sweat but not overexertion) was also
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with men comprising 77.3% of the active population and conducted during these sessions.
only 61% of the sedentary population (P =0.02). After The biobehavioral intervention group was compared
2 years of follow up, there were 7major adverse cardiac with a usual care group that received typical postsurgical
events in the active group and 13in the sedentary group follow-up care (with no specific counseling or individual-
(P=not significant). The 6-minute walk test improved in ized plan) as directed by patients primary care provider.
both groups postoperatively, with consistently higher scores Both intervention and usual care groups were similar in
in the active group. Functional outcomes, as measured by the QOL outcomes and symptom relief and symptom recur-
Veterans Specific Activity Questionnaire improved in both rence. An increase in exercise capacity, measured by peak
groups. Patient scores from the questionnaire were the same oxygen consumption (Vo2max) while undergoing treadmill
in the preoperative assessment; however, the score for the testing on the Bruce protocol, was noted in the interven-
active group at 2 years follow-up was significantly higher tion group (P,0.05). This difference was believed to be
than in the sedentary group (8.50 vs 6.99; P=0.02). From because of increased follow-through on prescribed home
this observational study, long-term adverse cardiac events exercise regimens in the intervention group. However, the
did not differ significantly between active and sedentary body mass index of patients in both cohorts increased during
patients in terms of LTPA, but active patients benefited from the study. This finding is consistent with other post-CABG
a greater increase in functional status outcomes compared cohorts, but it should be noted that the increase seen in this
with sedentary patients. study was to a lesser degree than in other reports.5,8 This
While this studys main goal was to examine major finding of increased body mass index is likely multifacto-
adverse cardiac events, the small sample size left the study rial and would benefit from further investigation to clarify
underpowered to detect small differences. Additionally, the attributable factors in this relationship, because it would
statistical analysis was simplified to only look for differences be desirable for many of these patients to lose or maintain
between active and sedentary patient outcomes at specific weight post-CABG.
time points; it would have been more useful to include Limitations of this study included a small sample size,
regression modeling to predict major adverse cardiac events reducing its power to detect differences in outcomes; that 30%
or to model functional status outcomes more thoroughly. The of eligible patients did not agree to participate for unknown
small sample size limits the conclusions that can be drawn reasons; and limited information was provided about the
from the study. The fact that several validated survey instru- exact intervention. However, success in the exercise arm of
ments were used enhances the usability and reproducibility the intervention indicated that behavioral interventions may
of the findings, and the focus of LTPA is somewhat unique. have a role in increasing exercise activity in the long-term
This study indicates that encouraging any type of LTPA in for patients who have undergone CABG surgery. This link
patients post-CABG may lead to long-term improvements in warrants further investigation in the post-CABG population
functional status outcomes. Further research is warranted to to build evidence for future practice guidelines.

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Diet and Exercise Interventions Post-CABG

Smith etal19 sought to determine the sustainability of Diet and Exercise


physical activity and QOL in patients undergoing 6months The need for emphasis on dietary advice by health care
of in-home or in-hospital CR after CABG surgery. In this providers to patients who had undergone CABG surgery
randomized clinical trial, 198 patients were initially random- was supported by Vachenauer etal.20 In a large retrospective
ized to either 6months of home- or hospital-based CR care cohort study that collected 5-year follow-up data on 2269
6 to 8 weeks post-CABG. Groups were similar in terms of patients who underwent CABG from 1990 through 2003,
medical condition and demographics. Exercise prescriptions adherence to prescribed dietary recommendations and patient
for both home and hospital groups were based on identical initiated requests for nutritional counseling both significantly
guidelines using Vo2max and heart rate limits. Participants decreased from the 19901998 to 20002003 CABG surgery
then received a 12-month follow-up visit after completion of groups (P,0.001 and P,0.0001, respectively). Fewer men
the CR program assigned. Upon discharge from CR, all par- than women followed strict dietary recommendations (20.0%
ticipants received the same exercise plan to follow during the vs 41.5%, respectively; P,0.001). Patients who had recur-
next 12months, and no interim follow-up was conducted. At rent angina were more likely to seek and follow advice on
the 12-month follow-up, Vo2max had declined from discharge diet and exercise than those who did not experience angina
of CR in the hospital group, while Vo2max was maintained (36.6% vs 29.8%, respectively; P =0.016). Additionally,
in the home-based CR group (P=0.002). The home-based patients with greater physical limitations as measured by
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group had higher habitual activity scores compared with New York Heart Association (NYHA) classification were
hospital-based rehabilitation at 12months as measured by more likely to adhere to recommended diet advice (adher-
the Physical Activity Scale for the Elderly scores (232.6 vs ence: NYHA III [22.2%] vs NYHA II [14.6%] vs NYHA I
170.0; P=0.005). Both groups had higher physical QOL [10.2%]; P,0.001). Men aged 60 to 79 years were more
scores than the initial score before CR as measured by the likely to exercise than women of the same ages (P,0.001).
Short Form-36 (SF-36) questionnaire (P=0.002). Patients This retrospective study showed a trend for reduced
in the home CR group also reported significantly increased adherence to recommended treatments over time in patients
social support than the hospital group as measured by the who had received instruction and advice about lifestyle
Interpersonal Support Evaluation List (P,0.05 for all sub- modifications. Additionally, a tendency to wait for symptom
scores). Participants in home-based CR (vs a hospital-based recurrence prior to implementation of recommended lifestyle
program) had increased Vo2max, increased habitual physi- modifications was found. Delays in initiating and sustaining
cal activity, and increased social support 12months after a diet and exercise components of self-management as part of
6-month CR program post-CABG surgery. usual daily routines can be especially problematic for patients
This study provides evidence that monitored, home-based who had CABG surgery for relief of cardiac symptoms, but
CR programs may provide superior long-term results to in whom latent CAD and atherosclerosis persists. Further
hospital-based programs. One theory to explain this finding research is needed to address barriers to dietary adherence
involves greater patient self-efficacy in exercise behaviors over time in an effort to improve long-term outcomes in
and activities initiated in the home environment, where the post-CABG population and slow or prevent progressive
patients live and conduct their usual daily routines. This worsening of atherosclerotic disease. This study found differ-
finding is one of several strengths of this study, in addition ences in adherence to recommended lifestyle modifications
to adequate power, validated measurement tools, and rigor- between age groups and sex, which have implications for
ous exercise programs that were similar across the groups. future research and individualized intervention approaches.
The major limitation of this trial is the inclusion criteria: Research focused on age and sex differences in diet and
patients must have been able to achieve 40% to 80% of exercise patterns, and motivations for following lifestyle
age- and sex-predicted maximum exercise test level, which modification recommendations in the post-CABG popula-
functionally limits the findings to low-risk patients in the tion is needed.
postoperative period post-CABG. However, an important In addition to findings discussed previously, long-term
question remains regarding the best course of treatment for lifestyle modifications can be inferred from intensive CR
moderate- to high-risk patients post-CABG. Further research programs used in post-myocardial infarction revasculariza-
is needed to address this issue in the moderate- and high-risk tion mixed cohort studies.11 In a recent mixed cohort of 1262
populations, and to determine the optimal exercise program patients undergoing any form of coronary revascularization
to initiate and monitor in the home environment. (69% of whom received CABG while the others received

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Coyan etal

primary PCI), diet control success was achieved in 909 (72%) Further research is needed to confirm the associations found
patients and increases in exercise were observed in 644 (51%) in this study using validated instruments for assessing long-
patients after 1 year. Pre-event sedentary lifestyle was pre- term diet and exercise behaviors in patients who underwent
dictive of poor diet post-event (odds ratio, 8.9). In addition, CABG surgery.
older patients who had $1 comorbidity had a tendency to
abandon diet recommendations during the course of the first Discussion
year postsurgery (odds ratio, 3.1). Notably, this study used This article highlights the current evidence on long-term
facilitator-led support groups versus structured supervised impact of diet and exercise lifestyle modifications in the
regimens, which may more accurately reflect real world post-CABG population. In the studies discussed, exercise
natural environments than tightly controlled clinical trials. resulted in significant increases in functional status and
In a similar fashion, multiple regression analysis was QOL. Functional outcomes were significantly improved with
conducted on prospective observational cohort data by exercise compared with functional outcomes in patients who
Lee21 to identify determinants of patient QOL 5 years post- did not exercise regularly. These factors are directly related
CABG surgery. Physical and mental QOL was measured in to increased psychological well-being, which can contribute
109 patients in face-to-face interviews 5 years after surgery to improved CAD outcomes.23 Additionally, CR has been
using the SF-36. The SF-36 is a validated survey useful shown to reduce depression in patients who undergo CABG,
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for quantifying health-related QOL, a measure of how although long-term effects remain unclear.24 Although
patients fare psychosocially and physically in response to decreases in the number of symptoms patients experienced
their overall health condition. Various component scores did not reach statistical significance in any of the reviewed
are useful in pinpointing particular health aspects, such as studies, it is possible that focused and individualized attempts
mental and physical components. In the present study, the to increase aerobic fitness level and respiratory function
Allied Dunbar National Fitness Survey diet sheet was used may improve symptoms and physical functioning over time.
to score actual dietary intake based on metrics indicating Research has shown that exercise post-CABG can improve
heart-healthy diet choices. A nonvalidated physical activity autonomic stability and symptoms in the short-term, but long-
questionnaire was used to quantify exercise for this study.22 term results remain unclear, as illustrated in this review.2528
Using both the mental and physical component scores of Additional research is needed to definitively determine the
the SF-36 as the dependent variables, hierarchic regression effects of diet and exercise on CAD symptoms post-CABG
analysis was conducted using dietary quality and physical surgery.
activity as independent variables. It is important to note that Overall, findings suggest that even intense cardiac interval
the physical component of the SF-36 is a measure of func- training was safe and effective in the post-CABG surgery
tional physical behaviors, not necessarily exercise or leisure patient population, but lower levels of exercise also provided
activity. Investigators found that physical activity scores 5 benefit. Patients need to adopt an individualized and feasible
years postsurgery were positively associated with physical exercise routine post-CABG surgery to achieve maximal
component scores of the SF-36 QOL indicators (P,0.001). recovery benefit and prevent progressive atherosclerotic
Additionally, diet scores were significantly associated with disease. Further research is needed to determine the optimum
mental QOL (P,0.035) in that healthier diets corresponded type of exercise routine for each patient, further define sex
to higher mental QOL scores. and age-specific differences in exercise recommendations,
Investigators concluded that several factors, including identify barriers to and facilitators of continued engagement
diet and physical activity, are associated with health-related in exercise, and specify the most useful objective physiologi-
QOL outcomes 5 years post-CABG. Several limitations cal outcomes in post-CABG exercise routines.
should be noted, including nonvalidated physical activity Based on the few available studies reviewed, enhancing
evaluation, small sample size, and potential concerns with healthy dietary patterns post-CABG surgery in an effort
the regression coefficients, because there were no diagnostics to avoid or slow progressive worsening of CAD warrants
discussed which leave several questions about the model increased attention by researchers and health care provid-
robustness related to multicollinearity and confounding. ers. Several of the studies demonstrated poor adherence to
However, the SF-36 was used to measure functional status guideline-based diet and exercise recommendations. Even
outcomes, and there was complete follow-up on the patients with intense short-term interventions, long-term dietary pat-
included in the study, which are both strengths of the study. terns often returned to baseline. It is well known that lifestyle

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Diet and Exercise Interventions Post-CABG

interventions, including diet and exercise interventions, can patients by health care providers other than their cardiotho-
be used to lower cholesterol in the short-term for patients racic surgeon to ensure long-term benefit of recommended
with CABG, but success with long-term reductions remains diet and exercise regimens.
elusive.29,30 Disease endpoints were demonstrably more diffi- In a recent review of factors affecting CR referral and
cult to quantify in the CABG surgery population, because few patient participation in coronary heart disease, Menezes
studies have examined outcomes in terms of worsening symp- etal33 found that referral for CR was disproportionately lower
toms or disease recurrence. Significant differences between for women than men, even though both sexes had similar
women and men in adopting dietary recommendations were clinical profiles. Furthermore, across the review of 23stud-
found and warrant further investigation.31 Research on sex ies,33 reasons for sex differences in CR referral included
and age differences in adherence to dietary recommendations age, personal resources, low rates of physician referral, and
post-CABG surgery is needed. In addition, intervention stud- weak recommendations to participation in CR programs.
ies are needed that effectively improve adherence and sustain These findings in the coronary heart disease population
high levels of engagement in therapeutic self-management are disturbing, given that initial referral for CR can sustain
behaviors over time. Interestingly, patients with recurrent engagement in exercise in the post-CABG population for the
angina (vs without recurring angina) were more likely to seek improvement of long-term outcomes. Additional research is
information and adhere to recommended dietary changes, needed to examine the reasons for non-referral and lack of
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perhaps because their symptoms provided a reminder of their participation in CR programs, to identify factors that influ-
disease process. Research is needed that focuses on patient ence sustained exercise, and whether a sex difference exists
education about atherosclerosis and possible intervention for referral. Similar findings were reported by Swift etal,34
strategies to ensure patients are aware of continued risks, where patients who had undergone urgent or elective PCI
despite reduced or absence of symptoms post-CABG surgery. and who engaged in CR experienced # 45% reduction in
There may be a significant role for multidisciplinary teams all-cause mortality regardless of age and sex. Thus, these
of primary care providers to aid patients post-CABG in sus- findings are significant for patients who not only underwent
taining necessary lifestyle modifications; this role should be CABG surgery, but also those who have had PCIs and those
a primary focus of future research. with medical management.
Adherence to lifestyle modifications continues to be Some general conclusions can be drawn to summarize
a pervasive health care problem in the post-CABG sur- the differences between men and women discovered in this
gery population.10 In a recent randomized trial at a large review. Several of the studies reviewed suggest that men are
Midwestern university medical center where optimal more likely to exercise multiple times each week and, on
medical treatment guidelines were implemented, including average, will exercise with higher intensity levels. However,
discharge teaching by a multidisciplinary team of pharma- women who do exercise have similar, and at times greater,
cists, dieticians, and rehabilitation nurses, an additional benefit than men in terms of QOL and functional outcomes.35
educational intervention was provided for the study group Conversely, men (vs women) are less likely to adhere long-
4 to 6 weeks after hospitalization for CABG. Long-term term to dietary advice. This seeming paradox may have to do
improvements in both the prescribed medication regimen with differences in perceived importance of diet and exercise
and lifestyle modifications post-CABG surgery were sub- recommendations between men and women. Additionally,
optimal in both groups.32 Although significant increases in it is important to note that women who undergo CABG, on
patient understanding and motivation were found during average, are older than men because of the later onset of CAD
the course of the study (P,0.05), significant decreases in women. This may mean that women are deconditioned
were found for medication compliance rates for important and have lower functional status because of advanced age at
cardiovascular medications (aspirin, angiotensin convert- surgery. Men who undergo CABG at a later age have similar
ing enzyme inhibitors, and -blockers) at 3 and 6months decreased functional status and exercise capacity; therefore
(P,0.05) for both the control and intervention groups. age may be a confounding factor when examining differences
While patients were motivated to follow guidelines, between the sexes.36 These general findings are remarkably
medication compliance rates decreased during the 1-year similar between all the studies reviewed that had enrolled
post-CABG period. Since surgical follow-up typically ends a substantial population of women. Additional research is
within weeks after surgery, long-term effects of lifestyle needed to determine the reasons for these observed differ-
modifications must be monitored and reinforced with ences between sex and age groups.

The Physician and Sportsmedicine, Volume 42, Issue 2, May 2014, ISSN 0091-3847 127
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Coyan etal

Notably, many of the studies reviewed had significant Future research that tests comprehensive diet and exercise
weaknesses that precluded drawing definitive conclusions interventions and assesses long-term engagement by patients
about the CABG cohort of patients. Methods employed to is needed to determine whether secondary prevention self-
measure attributes of diet and exercise across studies varied management interventions effectively improve long-term
widely, as did the interventions and their implementation in outcomes in patients post-CABG surgery. Clinical practice
the post-CABG patient population. Variation in study designs guidelines should include evidence on diet and exercise as
and reported findings rendered comparisons across studies critical secondary prevention measures to attenuate progres-
and conduct of a meta-analysis virtually impossible. As sive worsening of CAD after CABG. In the current health
indicated previously, several studies had significant selection care milieu, self-management behavioral interventions,
biases. For example, several studies selected patients who including therapeutic diet and exercise regimens should be
had opted to enroll in lifestyle modification programs before used with the same vigor as medication therapy to improve
study enrollment. These patients may have been motivated long-term CABG outcomes in patients and reduce health
to follow intervention instructions compared with those who care costs.
did not self-select to enroll. Many of the studies reviewed
were designed as observational studies, making it difficult Conclusion
to determine exactly what intervention component, if any, As the population ages and surgical technologies improve,
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led to improved outcomes. While both observational and the number of individuals undergoing CABG will continue
interventional study designs can be designed for rigor, studies to increase. Therefore, it will be important for health care
included in this review often lacked designs to reduce threats providers to structure appropriate long-term follow-up care
to internal validity. Future studies need clear conceptual and for this growing population, with the goal of effective sec-
operational definitions of diet and exercise and validated and ondary prevention of CAD, reducing hospitalizations and
reliable data collection instruments. Because long-term out- repeat revascularization procedures, and decreasing overall
come data are sorely needed in the post-CABG population, health care costs. Diet and exercise lifestyle modifications
studies designed to measure long-term outcomes are needed. have been shown in the limited studies available to have a
For example, epidemiological observational designs and potential significant role in improving post-CABG outcomes;
interventional studies with 1- to 2-year follow-up data col- thus, research that will effectively optimize and sustain the
lection can be used to measure the desired patient outcomes. positive effects of diet and exercise modifications will con-
Retrospective large database queries can be made to national tribute to build the evidence for clinical practice.
and regional (eg, state) health care databases and institutional
(eg, hospital and clinic) chart reviews for secondary analysis Conflict of Interest Statement
studies. Multidisciplinary multisite clinical trials on specific Garrett Coyan, MSc, is supported in part by a CTSA grant
diet and exercise interventions outcomes in the postdischarge from NCRR and NCATS awarded to the University of Kan-
environment are needed. sas Medical Center for Frontiers: The Heartland Institute
Several gaps in knowledge persist. For example, a nutri- for Clinical and Translational Research #TL1TR000120.
tious cardiac dietary program should be clearly described The contents are solely the responsibility of the authors and
to patients preparing for CABG surgery, with adequate do not necessarily represent the official views of the NIH,
methods for confirming patient understanding and ability NCRR, or NCATS. K. M. Reeder, PhD, RN, and James L.
to follow through with self-management of therapeutic diet Vacek, MD, MSc, disclose no conflicts of interest.
regimens postoperatively and over the course of the patients
lifetime. Although CR has been used with success during the
postoperative recovery period, continued long-term exercise
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