Outcome Analysis and Determinants of Major Adverse Cardiac Events in Young Adults After Coronary Artery Bypass Graft Surgery Who Participated in Early Phase II Cardiac Rehabilitation Program: A single-centre study
A cohort study from the Indonesian National Cardiovascular Center
Keywords:
Cardiac Rehabilitation, morbidity, mortality, prognosis
Abstract
Background: Cardiac rehabilitation (CR) program is proven to reduce mortality risk after coronary artery bypass surgery (CABG). Our study aimed to investigate the determinants of survival in young adult patients after CABG.
Method: This was a single-centre, longitudinal study with a survival analysis method from MACE of consecutive patients under 55 years old who underwent CABG and participated in the early phase II CR program between January 2017 and December 2018. The major adverse cardiac events (MACE) rates were determined over a 2-year follow-up time. Cox regression and Kaplan-Meier analysis were used to determine the predictors of the events based on the data registry.
Result: 279 patients who fulfilled the inclusion criteria were recruited in this study. MACE happened to 23 (8.45%) of them (3 patients died, 20 patients were hospitalised). Patients who dropped out (12%) from the CR program had a higher risk of developing events (HR 3.86, 95% CI 1.36-10.99). Of those who completed the CR program (245 patients), beta-blocker usage, chronotropic index, resting heart rate, and functional capacity after the CR program independently correlated with MACE. Six-minute walk distance (6-MWD) 376 meters was a significant predictor (p=0.001), with a shorter mean survival time of 6 months.
Conclusion: The early phase II CR program after CABG in young adult patients reduced the risk for cardiovascular mortality, major adverse events, and related readmission. It also increased the survival rate and mean survival time for participants who completed the CR program compared to dropouts. Optimum beta blocker medication, chronotropic index, resting heart rate, and functional capacity after the CR program are essential predictors of survival after CABG in young adults.
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References
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19. Dibben GO, Dalal HM, Taylor RS, Doherty P, Tang LH, Hillsdon M. Cardiac rehabilitation and physical activity: systematic review and meta-analysis. Heart. 2018;104(17):1394-402.
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24. Zwisler AD, Soja AM, Rasmussen S, Frederiksen M, Abedini S, Appel J, et al. Hospital-based comprehensive cardiac rehabilitation versus usual care among patients with congestive heart failure, ischemic heart disease, or high risk of ischemic heart disease: 12-month results of a randomized clinical trial. Am. Heart J. 2008;155(6):1106-13.
25. Mikkelsen T, Korsgaard Thomsen K, Tchijevitch O. Non-attendance and drop-out in cardiac rehabilitation among patients with ischaemic heart disease. Dan. Med. J.2014;61(10):A4919.
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27. Zhang H, Yuan X, Zhang H, Chen S, Zhao Y, Hua K, et al. Efficacy of Long-Term Beta Blocker Therapy for Secondary Prevention of Long-Term Outcomes After Coronary Artery Bypass Grafting Surgery. Circulation. 2015;131(25):2194-201.
28. Dayan V, Perez D, Silva E, Soca G, Estigarribia J. CABG and Preoperative use of Beta-Blockers in Patients with Stable Angina are Associated with Better Cardiovascular Survival. Braz J Cardiovasc. Surg. 2018;33(1):47-53.
29. Sousa-Uva M, Head SJ, Milojevic M, Collet JP, Landoni G, Castella M, et al. 2017 EACTS Guidelines on perioperative medication in adult cardiac surgery. Eur J Cardiothorac Surg. 2018; 53(1):5-33.
30. Dobre D, Zannad F, Keteyian SJ, Stevens SR, Rossignol P, Kitzman DW, et al. Association between resting heart rate, chronotropic index, and long-term outcomes in patients with heart failure receiving β-blocker therapy: data from the HF-ACTION trial. Eur. Heart J. 2013; 34(29):2271-80.
31. Dresing TJ, Blackstone EH, Pashkow FJ, Snader CE, Marwick TH, Lauer MS. Usefulness of impaired chronotropic response to exercise as a predictor of mortality, independent of the severity of coronary artery disease. Am. J. Card. 2000;86(6):602-9.
32. Gulati M, Shaw LJ, Thisted RA, Black HR, Bairey Merz CN, Arnsdorf MF. Heart rate response to exercise stress testing in asymptomatic women: the st. James women take heart project. Circulation. 2010;122(2):130-7.
33. Lauer MS, Francis GS, Okin PM, Pashkow FJ, Snader CE, Marwick TH. Impaired Chronotropic Response to Exercise Stress Testing as a Predictor of Mortality. JAMA. 1999;281(6):524-9.
34. Ehara M, Shibata K, Kameshima M, Konaka M, Fujiyama H, Katoh M, et al. Recovery from Chronotropic Incompetence during Phase II Cardiac Rehabilitation Contributes to the Better Future Cardiovascular Prognosis. J. Card. Fail. 2017;23(10):S59.
35. Zhang D, Shen X, Qi X. Resting heart rate and all-cause and cardiovascular mortality in the general population: a meta-analysis. CMAJ. 2016;188(3):E53-E63.
36. Menown IBA, Davies S, Gupta S, Kalra PR, Lang CC, Morley C, et al. Resting heart rate and outcomes in patients with cardiovascular disease: where do we currently stand? Cardiovasc. Ther. 2013;31(4):215-23.
37. Vitale G, Sarullo S, Vassallo L, Di Franco A, Mandalà G, Marazia S, et al. Prognostic Value of the 6-Min Walk Test After Open-Heart Valve Surgery: Experience of a cardiovascular rehabilitation program. J Cardiopulm Rehabil Prev. 2018;38(5):304-8.
38. Osailan A, Abdelbasset WK. Exercise-based cardiac rehabilitation for postcoronary artery bypass grafting and its effect on hemodynamic responses and functional capacity evaluated using the Incremental Shuttle Walking Test: A retrospective pilot analysis. J Saudi Heart Assoc. 2020 ;32(1):25-33.
2. Mendes M. Is There a Role for Cardiac Rehabilitation After Coronary Artery Bypass Grafting? Circulation. 2016;133(24):2538-43.
3. Wenger NK. Current status of cardiac rehabilitation. J. Am. Col. Cardiol. 2008;51(17):1619-31.
4. Hillis LD, Smith PK, Anderson JL, Bittl JA, Bridges CR, Byrne JG, et al. 2011 ACCF/AHA Guideline for Coronary Artery Bypass Graft Surgery. A Report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines Developed in Collaboration With the American Association for Thoracic Surgery, Society of Cardiovascular Anesthesiologists, and Society of Thoracic Surgeons 2011;58(24):e123-e210.
5. Martin BJ, Hauer T, Arena R, Austford LD, Galbraith PD, Lewin AM, et al. Cardiac rehabilitation attendance and outcomes in coronary artery disease patients. Circulation. 2012;126(6):677-87.
6. 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: a community-based study. Circulation. 2013;128(6):590-7.
7. Dalén M, Ivert T, Holzmann MJ, Sartipy U. Coronary Artery Bypass Grafting in Patients 50 Years or Younger. Circulation. 2015;131(20):1748-54.
8. Rosato S, Biancari F, D’Errigo P, Fusco D, Seccareccia F. Midterm Outcome of Coronary Artery Bypass Grafting in Young Patients: A Multicenter Italian Study. Ann. Thorac. Surg. 2015;100(5):1689-96.
9. Saraiva J, Antunes PE, Antunes MJ. Coronary artery bypass surgery in young adults: excellent perioperative results and long-term survival. Interact Cardiovasc Thorac Surg. 2017;24(5):691-5.
10. Anderson L, Thompson DR, Oldridge N, Zwisler AD, Rees K, Martin N, et al. Exercise-based cardiac rehabilitation for coronary heart disease. The Cochrane database of systematic reviews. 2016;2016(1):Cd001800.
11. Pardaens S, Willems AM, Clays E, Baert A, Vanderheyden M, Verstreken S, et al. The impact of drop-out in cardiac rehabilitation on outcome among coronary artery disease patients. Eur. J. Prev. Cardiol. 2017;24(14):1490-7.
12. La Rovere MT, Pinna GD, Maestri R, Olmetti F, Paganini V, Riccardi G, et al. The 6-minute walking test and all-cause mortality in patients undergoing a post-cardiac surgery rehabilitation program. Eur. J. Prev. Cardiol.2013;22(1):20-6.
13. Kadda O, Kotanidou A, Manginas A, Stavridis G, Nanas S, Panagiotakos DB. Lifestyle intervention and one-year prognosis of patients following open heart surgery: a randomised clinical trial. J. Clin. Nurs.. 2015;24(11-12):1611-21.
14. Kureshi F, Kennedy KF, Jones PG, Thomas RJ, Arnold SV, Sharma P, et al. Association Between Cardiac Rehabilitation Participation and Health Status Outcomes After Acute Myocardial Infarction. JAMA Cadiol. 2016;1(9):980-8.
15. Heran BS, Chen JM, Ebrahim S, Moxham T, Oldridge N, Rees K, et al. Exercise-based cardiac rehabilitation for coronary heart disease. The Cochrane database of systematic reviews. 2011(7):Cd001800.
16. Graham HL, Lac A, Lee H, Benton MJ. Predicting Long-Term Mortality, Morbidity, and Survival Outcomes Following a Cardiac Event: A Cardiac Rehabilitation Study. Rebabil. Process Outcome. 2019;8:1179572719827610.
17. Cacciatore F, Abete P, Mazzella F, Furgi G, Nicolino A, Longobardi G, et al. Six-minute walking test but not ejection fraction predicts mortality in elderly patients undergoing cardiac rehabilitation following coronary artery bypass grafting. Eur. J. Prev. Cardiol.2011;19(6):1401-9.
18. Mukherjee D, Hsu A, Moliterno DJ, Lincoff AM, Goormastic M, Topol EJ. Risk factors for premature coronary artery disease and determinants of adverse outcomes after revascularization in patients ≤40 years old. Am. J. Card. 2003;92(12):1465-7.
19. Dibben GO, Dalal HM, Taylor RS, Doherty P, Tang LH, Hillsdon M. Cardiac rehabilitation and physical activity: systematic review and meta-analysis. Heart. 2018;104(17):1394-402.
20. Dunlay SM, Pack QR, Thomas RJ, Killian JM, Roger VL. Participation in cardiac rehabilitation, readmissions, and death after acute myocardial infarction. Am. J. Med. 2014;127(6):538-46.
21. Oliveira NL, Ribeiro F, Teixeira M, Campos L, Alves AJ, Silva G, et al. Effect of 8-week exercise-based cardiac rehabilitation on cardiac autonomic function: A randomized controlled trial in myocardial infarction patients. Am. Heart J.2014;167(5):753-61.e3.
22. Song R, Lee H. Effects of a 12-week cardiac rehabilitation exercise program on motivation and health-promoting lifestyle. Heart Lung. 2001;30(3):200-9.
23. West RR, Jones DA, Henderson AH. Rehabilitation after myocardial infarction trial (RAMIT): multi-centre randomised controlled trial of comprehensive cardiac rehabilitation in patients following acute myocardial infarction. Heart. 2012;98(8):637-44.
24. Zwisler AD, Soja AM, Rasmussen S, Frederiksen M, Abedini S, Appel J, et al. Hospital-based comprehensive cardiac rehabilitation versus usual care among patients with congestive heart failure, ischemic heart disease, or high risk of ischemic heart disease: 12-month results of a randomized clinical trial. Am. Heart J. 2008;155(6):1106-13.
25. Mikkelsen T, Korsgaard Thomsen K, Tchijevitch O. Non-attendance and drop-out in cardiac rehabilitation among patients with ischaemic heart disease. Dan. Med. J.2014;61(10):A4919.
26. Hlatky MA, Solomon MD, Shilane D, Leong TK, Brindis R, Go AS. Use of medications for secondary prevention after coronary bypass surgery compared with percutaneous coronary intervention. J. Am. Col Cardiol. 2013;61(3):295-301.
27. Zhang H, Yuan X, Zhang H, Chen S, Zhao Y, Hua K, et al. Efficacy of Long-Term Beta Blocker Therapy for Secondary Prevention of Long-Term Outcomes After Coronary Artery Bypass Grafting Surgery. Circulation. 2015;131(25):2194-201.
28. Dayan V, Perez D, Silva E, Soca G, Estigarribia J. CABG and Preoperative use of Beta-Blockers in Patients with Stable Angina are Associated with Better Cardiovascular Survival. Braz J Cardiovasc. Surg. 2018;33(1):47-53.
29. Sousa-Uva M, Head SJ, Milojevic M, Collet JP, Landoni G, Castella M, et al. 2017 EACTS Guidelines on perioperative medication in adult cardiac surgery. Eur J Cardiothorac Surg. 2018; 53(1):5-33.
30. Dobre D, Zannad F, Keteyian SJ, Stevens SR, Rossignol P, Kitzman DW, et al. Association between resting heart rate, chronotropic index, and long-term outcomes in patients with heart failure receiving β-blocker therapy: data from the HF-ACTION trial. Eur. Heart J. 2013; 34(29):2271-80.
31. Dresing TJ, Blackstone EH, Pashkow FJ, Snader CE, Marwick TH, Lauer MS. Usefulness of impaired chronotropic response to exercise as a predictor of mortality, independent of the severity of coronary artery disease. Am. J. Card. 2000;86(6):602-9.
32. Gulati M, Shaw LJ, Thisted RA, Black HR, Bairey Merz CN, Arnsdorf MF. Heart rate response to exercise stress testing in asymptomatic women: the st. James women take heart project. Circulation. 2010;122(2):130-7.
33. Lauer MS, Francis GS, Okin PM, Pashkow FJ, Snader CE, Marwick TH. Impaired Chronotropic Response to Exercise Stress Testing as a Predictor of Mortality. JAMA. 1999;281(6):524-9.
34. Ehara M, Shibata K, Kameshima M, Konaka M, Fujiyama H, Katoh M, et al. Recovery from Chronotropic Incompetence during Phase II Cardiac Rehabilitation Contributes to the Better Future Cardiovascular Prognosis. J. Card. Fail. 2017;23(10):S59.
35. Zhang D, Shen X, Qi X. Resting heart rate and all-cause and cardiovascular mortality in the general population: a meta-analysis. CMAJ. 2016;188(3):E53-E63.
36. Menown IBA, Davies S, Gupta S, Kalra PR, Lang CC, Morley C, et al. Resting heart rate and outcomes in patients with cardiovascular disease: where do we currently stand? Cardiovasc. Ther. 2013;31(4):215-23.
37. Vitale G, Sarullo S, Vassallo L, Di Franco A, Mandalà G, Marazia S, et al. Prognostic Value of the 6-Min Walk Test After Open-Heart Valve Surgery: Experience of a cardiovascular rehabilitation program. J Cardiopulm Rehabil Prev. 2018;38(5):304-8.
38. Osailan A, Abdelbasset WK. Exercise-based cardiac rehabilitation for postcoronary artery bypass grafting and its effect on hemodynamic responses and functional capacity evaluated using the Incremental Shuttle Walking Test: A retrospective pilot analysis. J Saudi Heart Assoc. 2020 ;32(1):25-33.
Published
2025-07-29
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How to Cite
Radi, B., Intan, R., Dwiputra, B., Desandri, D., & Ambari, A. (2025). Outcome Analysis and Determinants of Major Adverse Cardiac Events in Young Adults After Coronary Artery Bypass Graft Surgery Who Participated in Early Phase II Cardiac Rehabilitation Program: A single-centre study. Indonesian Journal of Cardiology, 45(4). https://doi.org/10.30701/ijc.1727
Section
Clinical Research
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