Cardiac rehabilitation after coronary artery bypass graft surgery: urgently needed!

Coronary artery bypass graft surgery has proven effective in relieving anginal symptoms and prolonging survival in many subsets of coronary artery disease patients [1]. This finding has led to the extensive application of this procedure in recent years. In Israel the annual number of CABG-treated patients is approximately 5,500. However, the above benefits of CABG are not parallelled by the expected beneficial effect in other qualityof-life domains, including aspects of both physical and psychosocial well being. Employment rates in surgically treated patients are disappointing in that they do not exceed those in patients treated medically [2±6] and generally are not higher than rates after an acute myocardial infarction. Post-CABG employment status has not substantially improved over the past decades despite the improvement in surgical techniques. Many post-CABG patients suffer from bodily pain, usually of a musculoskeletal nature, that they often tend to attribute to cardiac origin. Anxiety and depression are frequently encountered in postCABG patients [1]. Anxiety may enhance sympathetic nervous system activity and complicate patient care. The prevalence of depression is about 33% [7], similar to that in post-myocardial infarction patients. Depression may complicate physical and psychosocial recovery and is also a documented risk factor for recurrent cardiac events [8,9]. Thus, the realization of one's mortality, physical limitations, limitations of sexual and vocational activities, and the development of nihilism regarding the modification of risk factors may adversely affect recovery. Neurocognitive sequelae of the operation may also impair quality of life. In addition, the benefit of CABG with regard to both symptom relief and mortality decreases over the long term (10 years) due to the progression of graft and native coronary atherosclerosis [1]. Therefore, there is a need for intensive efforts to screen for and treat coronary artery disease risk factors in post-CABG patients [1,10,11]. All smokers should receive educational counseling and be offered smoking cessation therapy after CABG [1]. Also indicated are aggressive lipidlowering therapy, control of high blood pressure and body weight, and regular physical activity [1,10]. The participation of post-CABG patients in a comprehensive cardiac rehabilitation program may be the appropriate response to the above mentioned issues. Such programs consist of physical exercise together with education, counseling and behavior-modification strategies aimed at reducing coronary disease risk factors and modifying lifestyle and health-related behaviors [10]. Extensive research [10] points to the beneficial effects of cardiac rehabilitation on exercise tolerance, symptoms of angina and heart failure, blood lipid levels, carbohydrate and insulin metabolism, body weight and blood pressure control, psychological well being, psychosocial functioning and rate of progression of coronary atherosclerosis, as well as on mortality rates. Studies have reported a 25% reduction in mortality following participation in a cardiac rehabilitation program [10,12,13]. Improved endothelial function is an additional potential benefit of cardiac rehabilitation [14]. The cost-effectiveness of cardiac rehabilitation services is also well documented [10,15]. During a 3 year follow-up of an American patient sample after coronary events, 58% of which were CABG operations, per capita hospitalization charges were $739 lower for rehabilitated patients than for non-participants [15]. The cost-effectiveness of cardiac rehabilitation stems from both a decrease in healthcare utilization costs (recurrent hospitalizations, invasive procedures and physician and emergency room referrals) and an increase in productive employment. Current practice guidelines [1,16] encourage participation of post-CABG patients in such programs. Recent American College of Cardiology/American Heart Association guidelines for CABG surgery [1] emphasized that ``cardiac rehabilitation should be offered to all eligible patients after coronary bypass surgery. '' CABG = coronary artery bypass grafting