Hawkes et al left ventricular functioning have a particularly poor prognosis when treated medically, and benefit from CABG. Recent studies suggest that the use of the left internal thoracic artery to the left anterior descending coronary artery, and potentially multiple arterial revascularization, improves survival and reduces late cardiac events after CABG (Loop et al 1986; Yusuf et al 1994; Cameron et al 1996). Furthermore, off-pump CABG may offer fewer early complications, particularly in those patients with significant comorbidity (Pepper 2005). Data are less clear for patients with single- or double-vessel disease, or with normal left ventricular functioning. For these patients, many other variables must be taken into account when assessing the benefits of surgery including the patient’s level of physical functioning, psychological functioning, social functioning, and vocational status (Allen 1990). Physical functioning Improved functional status and return to pre-morbid lifestyle is a major goal for most patients undergoing CABG. Relief of angina and dyspnea, level of physical activity, complications of surgery, and re-hospitalization have been investigated when assessing physical functioning (Jenkins et al 1983; Herlitz et al 2001). Relief from angina and dyspnea Incapacitating angina is the most common indication for CABG. Results of observational studies and randomized controlled trials of medical versus surgical treatment have demonstrated that in patients with disabling angina pectoris, surgery results in relief from symptoms and decreased need for anti-anginal medication (Herlitz et al 2001). A review of 14 controlled clinical trials demonstrated that the likelihood of becoming angina-free was approximately 40% greater in the surgical than the medical group (Wortman and Yeaton 1985). A more recent study found that 80% of CABG patients were angina-free up to 5 years after surgery (Fihn et al 2001). Breathlessness, or dyspnea, following CABG has also been investigated (Jenkins et al 1983; Mayou and Bryant 1987; Sjoland et al 1997b; Herlitz et al 2001). In a study in which 60% of patients experienced dyspnea before CABG, 54% of these were completely relieved of dyspnea, 22% reported some improvement, and 18% had no improvement 6 months following surgery. Nine percent of the total patient group reported more dyspnea following surgery, with more than 50% of these reports being from patients without dyspnea pre- surgery (Jenkins et al 1983). Another study found that 71% of patients experienced dyspnea before surgery whilst 39% reported it 12 months post-surgery (Mayou and Bryant 1987). In a later study, 63% of CABG patients complained of dyspnea pre-surgery, with the proportion falling to 30% at three months and 33% at 12 months. The level of exertion at which these symptoms developed was also greater after surgery (Caine et al 1991). More recently, symptoms of chest pain and dyspnea were significantly reduced in both male and female patients following CABG (Sjoland et al 1997b; Herlitz et al 2001). Thus in general, an improvement in angina and dyspnea has been observed following CABG. Physical activity Increased maximal exercise performance after CABG has been reported in a number of studies (Jenkins et al 1983; Caine et al 1991; Chocron et al 1996; Sjoland et al 1997a; Herlitz et al 2001). One study found that 6 months after CABG, usual daily physical activity had increased, with a sharp reduction in the number of days participants were unable to carry out usual activities, or were confined to bed, due to their heart condition (Jenkins et al 1983). An investigation of usual activity levels at home, at leisure, and socially, found that these were improved 1 year following surgery (Caine et al 1991). An assessment of QOL before and 3 months after heart surgery found that physical mobility was improved in 77% of patients (Chocron et al 1996). One study developed a physical activity score containing six questions for the self-estimation of physical abilities and limitations. The score improved over time, with the major improvement observed at 3 months, and further slight improvement at 2 years (Sjoland et al 1997a). In contrast, other researchers have found no change, or a decrease, in physical functioning following CABG. One study found that 17% of previously active CABG patients reported a significant decrease in leisure and social activities up to 2 years after surgery (Wilson-Barnett 1981). Investigators in the CASS found that 68% of patients had a moderate activity level pre-surgery with no change in activity during the 5-year follow-up period (CASS PI 1983). More recently, an investigation of exercise behavior at 6 and 24 months post-surgery found that 67% of CABG patients had become long-term regular exercizers by 2 years post-surgery (Jue and Cunningham 1998). These results support the view of Allen (1990) that physical functioning improves for some patients following CABG, while pre-operative inactivity continues or physical activity levels deteriorate following surgery for other patients (Allen 1990). 480 Vascular Health and Risk Management 2006:2(4)