Vol 4 No 3 full text final.indd


Althea Medical Journal. 2017;4(3)

479

Effect of Short Term Cardiac Rehabilitation Program on Quality of Life 
in Patients with Coronary Artery Disease

Ina Marita,1 Sunaryo B. Sastradimaja,2 Badai Bhatara Tiksnadi3
1Faculty of Medicine Universitas Padjadjaran, 2Department of Physical Medicine and 

Rehabilitation Faculty of Medicine Universitas Padjadjaran/Dr. Hasan Sadikin General Hospital 
Bandung, 3Department of Cardiology and Vascular Medicine Faculty of Medicine Universitas 

Padjadjaran/Dr. Hasan Sadikin General Hospital Bandung

Abstract

Background: Cardiac rehabilitation (CR) programs are known to be one of the effective managements 
which aim to improve the quality of life (QoL) in coronary artery disease (CAD). However, there is still 
controversy about the effect on QoL dimension. The purpose of this study is to determine the effect of short 
term cardiac rehabilitation program on quality of life in patients with coronary artery disease.
Methods: The study design used was a quasi experimental study with repeated measurements in consecutive 
sampling involving 11 subjects with CAD from September–November 2015 in Cardiorespiratory Clinic and 
Gymnasium of Physical Medicine and Rehabilitation and Cardiac Unit Services, Dr. Hasan Sadikin General 
Hospital Bandung. The cardiac rehabilitation program was performed for 4 weeks. The quality of life was 
scored using medical outcomes study short form 36 (SF-36) questionnaire before and after CR program. 
Statistics obtained in this study were analyzed using paired t-test and Wilcoxon test.
Results: This study involved 11 male patients with CAD with an average age of 58 (11) years old with the 
diagnosis of CAD post CABG (n=6), CAD post PCI (n=4), and CAD unrevascularized (n=1). The average total 
score of quality of life questionnaire SF-36 demonstrated a significant increase (p<0.001) after CR program 
87.27(8.5) as compared to before CR program 49.09(8.4). This improvement occurred in all QoL dimensions.
Conclusions: Short term cardiac rehabilitation program can improve the quality of life in patients with 
coronary artery disease.

Keywords: Cardiac rehabilitation, coronary artery disease, quality of life

Introduction

Based on the world health organization 
(WHO) in 2012, cardiovascular disease is the 
leading cause of death, representing 31% 
of total deaths worldwide. Of these deaths, 
the highest rate is due to coronary artery 
disease (CAD) that has high mortality and 
morbidity rate.1,2 Management of CAD has 
been progressing rapidly either by medication 
or surgical intervention. Nevertheless, cardiac 
rehabilitation (CR) has an important role in the 
management of CAD as it has been proven to be 
effective in reducing mortality and morbidity 
rate, reducing health care cost, significantly 
increasing patient’s functional capacity and 
quality of life, especially in women.3 This 

program can be performed both in health care 
facility and at home with the same effectivity 
rate.4

Quality of life (QoL) has been widely used as a 
criteria in assessing the outcomes of treatment 
and intervention given to the patients.5 Quality 
of life can be defined as a complex, subjective, 
and multidimensional concept which 
represents a patient’s perception or subjective 
evaluation of the impact of disease on their 
functional status and well being.6 Various 
studies have been conducted to observe the 
effectiveness of cardiac rehabilitation program 
on QoL in various time periods. However, 
there is still controversy about the effect on 
QoL dimension. Nonetheless, studies about 
the effect of cardiac rehabilitation programs 
on the quality of life in shorter periods are 

Correspondence: Ina Marita, Faculty of Medicine, Universitas Padjadjaran, Jalan Raya Bandung-Sumedang Km.21, 
Jatinangor, Sumedang, Indonesia,  Email: inamarita53@gmail.com

AMJ. 2017;4(3):479-85

ISSN 2337-4330  ||  doi: http://dx.doi.org/10.15850/amj.v4n3.1207



Althea Medical Journal. 2017;4(3)

480     AMJ September 2017

still limited in Indonesia. The aim of this study 
was to observe the effect of short term cardiac 
rehabilitation program on quality of life in 
patients with coronary artery disease.

Methods

This quasi experimental study without control 
group was conducted from September–
November 2015. The population of this study 
included all CAD patients in Cardiorespiratory 
Clinic and Gymnasium of Physical Medicine 
and Rehabilitation and Cardiac Unit Services, 
Dr. Hasan Sadikin General Hospital Bandung. 
Minimum samples needed for this study were 
11 subjects. The samples were taken with 
consecutive sampling method. The subjects 
were given an informed consent form as a 
proof of agreement to participate in this study. 
This study had received ethical approval from 
Health Research Ethics Committee Faculty of 
Medicine Universitas Padjadjaran. 

The subject inclusion criteria were patients 
with CAD who agreed to participate as study 
subjects and were cooperative in answering 
questions throughout an interview session. 
Meanwhile, patients with unstable angina, 
uncontrolled risk factors, neuro-orthopedic 
pathological conditions that may affect 
exercise capacity, and who recently (<2 weeks) 
underwent surgical interventions such as 
percutaneous coronary intervention (PCI)/
coronary artery bypass graft (CABG) were 
excluded from this study. Drop out criteria 
were patients who did not return for final 
evaluation, did not finish exercise phases for 4 
weeks, only performed exercise <4 times out of 
total hospital visits, <8 times out of total home 
exercise, and did not perform any exercise 5 
times in a row. 

Before the rehabilitation program, vital 
signs were measured and submaximal exercise 
test was performed to determine subject’s 
basic exercise capacity using a 6-minute 
walking test. All subjects who underwent the 
cardiac rehabilitation program were given an 
aerobic exercise modality by using a treadmill 
under doctor’s supervision in the hospital as 
well as walking at home with a frequency of 
3–5 times per week (2 times in the hospital 
and 3 times at home). Each exercise modality 
duration was ≥ 30 minutes which consisted 
of  ≥5 minutes warm-up, ≥20 minutes aerobic 
exercise, and ≥5 minutes cool-down, and 
intensity exercise in the hospital was 60–70% 
of the VO2 max or 70–85% of maximum heart 
rate, while the home exercises were 60–75% 
of maximum heart rate.

This CR program was performed for 4 
weeks. In every hospital visit, the subjects were 
given education and counselling about risk 
factor modifications and stress management. 
During home exercise, subjects were asked 
to walk on a flat surface around the patient’s 
home at a pace that had been adapted to the 
patient’s condition. The exercise distance was 
specified by the doctor.

Subject’s quality of life was measured by 
medical outcomes study short form 36 (SF-
36) questionnaire which has been widely 
used in Indonesia as well as other countries. 
The Indonesian version of the questionnaire 
had been validated and was used for outcome 
measurement in this study. The questionnaire 
was composed of 36 questions assessing 
physical and mental health components. 
Physical health component included 4 
dimensions: physical function (PF), physical 
limitation (PL), body pain (BP), and vitality 
(V). The dimension that reflected mental 
health components were social function (SF), 
emotional limitation (EL), mental health (MH), 
and general health (GH). Each question was 
scored on a scale from 0 (maximal limitation) 
to 100 (no limitation). Every score from 
those questions that addressed each specific 
dimension were than averaged together, 
resulting in a final score within each of the 8 
dimensions.7

The data were analyzed with statistical 
computer software. Bivariate analysis 
was performed to observe the correlation 
between the dependent and independent 
variables. Normality test using Shapiro-wilk 
was performed to assess data distribution. 
Data with normal distribution were assessed 
with paired t-test, while data with abnormal 
distribution were assessed with Wilcoxon test. 
The confidence interval (CI) used in this study 
was 95%.

Results

The subjects were recruited using consecutive 
sampling. Subjects included 11 patients with 
coronary artery disease. All subjects were 
males with an average age of 58 years old. Most 
subjects had undergone revascularization in 
the form of CABG (Table 1).

Descriptive statistical analysis was 
performed on the data collected to obtain 
the average total score and the average score 
of each dimension of QoL. Then, the data 
collected were analyzed statistically. The data 
for normality test using Saphiro-Wilk were 
obtained to determine the total score of QoL, 



Althea Medical Journal. 2017;4(3)

481Ina Marita, Sunaryo B. Sastradimaja, Badai Bhatara Tiksnadi: Effect of Short Term Cardiac Rehabilitation 
Program on Quality of Life in Patients with Coronary Artery Disease

physical and mental component, dimension of 
physical functionality, vitality, mental health, 
and social functions which had normal data 
distribution. Thus, the data were interpreted 
using a parametric test, paired t-test. 
Meanwhile, the score of dimensions in physical 
limitations, emotional limitations, bodily pain, 
and general health had anabnormal data 
distribution, so the alternative nonparametric 
Wilcoxon test was used.

There were significant differences between 
the mean score of QoL before and after 
CR program (Table 2). Based on the SF-36 
questionnaire, QoL can be divided into two 
large components consisting of physical and 
mental health components. The result shows 
significant differences between the average 
scores on the physical and mental health 
components of the patients before and after 

CR program (Table 2).
Additionally, the questionnaire can also 

be divided into eight dimensions: physical 
function, physical limitation, emotional 
limitation, vitality, mental health, social 
function, body pain, and general health. 

Based on the p-values in Table 3, there 
were significant differences between the QoL 
of patients before and after CR program in all 
QoL dimensions.

Discussion

Coronary artery disease (CAD) is the leading 
cause of death in the world with high mortality 
and morbidity rate.1,2 Cardiac rehabilitation 
program has largely demonstrated their 
long-term efficacy in reducing mortality and 
morbidity rate, increasing patient’s functional 

Table 1 Characteristics of Subject 
Variable (n=11) Mean(SD) n

Age (year) 58 (11)
Weight (kg) 65.18 (6.9)
Height (m) 1.63 (0.1)
BMI (kg/m2) 24.5 (2.5)
Diagnosis
    CAD unrevascularized 1
    CAD post CABG 6
    CAD post PCI 4
Gender
    Male 11
    Female 0
Education
    Elementary school 3
    Junior high school 1
    Senior high school 3
    College 4
Marital Status
    Married 10
    Single 1
Occupation
    Working 8
    Not working 3

Note : BMI= Body Mass Index; CAD= Coronary artery disease; CABG= Coronary artery bypass graft; PCI= Percutaneous 
Coronary Intervention; age, weight, height and BMI are presented as mean (standard deviation)



Althea Medical Journal. 2017;4(3)

482     AMJ September 2017

capacity and quality of life, and reducing risks 
that can arise from CAD and its complications.8

In this study, 11 people with CAD 
participated in cardiac rehabilitation program 
for 4 weeks. Based on the total study subjects, 
it can be said that the participation of the 
patient in cardiac rehabilitation is still quite 
low. This is supported by a study of Karam 
et al.9 showing that the level of patient 
participation in cardiac rehabilitation is <50% 
in most countries, with the drop-out rate 
reaching 56% in high-income countries and 
82% in middle-income countries. 

All study subjects in this study were male. 
The low participation of females in this 
program is supported by a study from Samayoa 
et al.10 showing that women’s participation in 
CR program is significantly lower compared to 
men, women (36%) are less likely to enroll in  
CR programs. 

Results of this study showed that there was 
an increase in average scores in all dimensions 
of quality of life significantly after cardiac 

rehabilitation program for 4 weeks. This study 
showed that the effect of a shorter but optimal 
cardiac rehabilitation conducted for 4 weeks 
with consistent surveillance can increase 
the quality of life of the patient mentally dan 
physically as good as a cardiac rehabilitation 
process conducted for a longer period of time. 
The results were consistent with the findings 
of several studies that have been done before. 
A study conducted by Saedi et al.3 showed that 
QoL in 100 patients with CAD who followed 
cardiac rehabilitation for 8 weeks improve 
significantly. Freitas et al.11 showed that patients’ 
physical and mental health component of QoL 
improve significantly after 4-week cardiac 
rehabilitation program. The same findings 
were obtained from the study of Lee et al.12 
after undergoing cardiac rehabilitation within 
12 weeks. A study conducted by Tavella et al.13 
on CAD patients who followed a CR program 
for 6 weeks showed that QoL is improved even 
for 6 months after the program. However, 
when compared with the control, there was no 

Table 2 Quality of Life Score Differences based on Physical and Mental Components in 
  Patients with Coronary Artery Disease before and after Cardiac Rehabilitation 
  Program 

Scale
CR Program

p valueBefore 
(mean, SD)

After 
(mean, SD)

Physical health component 34.04 (5.7) 87.16 (10.9) <0.001
Mental health component 63.93 (15.4) 87.29 (8.8) <0.001
Quality of life score 49.09 (8.4) 87.27 (8.5) <0.001

Note : SD= Standard deviation

Table 3 Dimensional Scores Differences of Quality of Life in Patients with Coronary Artery 
  Disease before and after Cardiac Rehabilitation Program 

Scale
CR Program

p value
Before After 

Physical function* 35.45 (9.1) 89.36 (8.5) <0.001
Physical limitation** 0.00 (0-25) 100 (50-100) 0.003
Emotional limitation** 67 (0-100) 100 (67-100) 0.027
Vitality* 64.09 (14.6) 80.45 (12.1) <0.001
Mental health* 82.55 (10.3) 88.00 (6.7) <0.001
Social function* 48.55 (12.3) 83.73 (15) <0.001
Body pain** 22 (0-55) 100 (68-100) 0.003
General health** 70 (45-75) 80 (75-100) 0.003

Note: *: paired t-test (if normal distribution). Data were presented in mean and standard deviation, **: Wilcoxon test (if 
abnormal distribution). Data were presented in median, minimum value and maximum value



Althea Medical Journal. 2017;4(3)

483

significant difference.13
Quality of life can be divided into two major 

components, which are physical and mental 
health components. In the present study, 
physical health component score increased 
significantly after CR in total population. It 
can be explained as follows: the primary effect 
of aerobic exercise training is to increase 
maximal stroke volume (SV) and maximal 
arterial-venous O2 difference (A-V O2 Δ), 
resulting in an increase of maximal exercise 
capacity (VO2max). There are multiple 
factors that can influence improvement in 
VO2max, including age, baseline exercise 
capacity, characteristics of the training 
regimen, and genetic factors. Exercise-based 
rehabilitation increases the body’s oxygen 
demand measured as the ventilatory oxygen 
uptake (V̇O2). Rearranging the Fick equation, 
V̇O2 is determined by the product of (cardiac 
output) and A-V O2. Increasing either heart 
rate (HR) or stroke volume (SV) increases 
Q. Whereas Q is determined by the absolute 
V̇O2; HR and systolic blood pressure (SBP) 
response, an index of myocardial oxygen 
requirements (MO2), or internal work rate 
are determined by the V̇O2 requirements of a 
physical task relative to maximal capacity or 
the percent V̇O2max. Exercise training raises 
the ventilatory threshold (VT) which indicates 
the maximal steady state or work rate that 
can be maintained during submaximal 
exercise and increased endurance capacity in 
cardiac patients. In conclusion, the increase in 

V̇O2max means that any submaximal physical 
task represents a smaller percent V̇O2max, 
produces a slower HR and lower SBP, raises 
the VT, and therefore, requires a lower MO2.

14

In this study, the average mental health 
component scores increased significantly after 
the CR program. These results are comparable 
to the study of Freitas et al.11 that showed 
patient’s psychological parameters such as 
anxiety and depression were improved after 
CR for 4 weeks. Poortaghi et al.15 compared 
a group which received routine centre-based 
CR programs combined with home visits of a 
community health nurse throughout the follow-
up period with centre-based CR programs 
alone. Improvements inpatient’s self efficacy 
showed statistically significant differences 
between two studied groups.15 The findings of 
that study were the same as the results of the 
study by Lee et al.16 in 2013. An investigation 
by Sharif et al.17 on CAD patients undergoing 
CABG showed that cardiac rehabilitation is 
effective in reducing depression for almost 2 
months after surgery. In addition, the decrease 
in anxiety is not statistically significant.17 
However, there are some investigations with 
different findings; the study conducted by 
Weberg et al.18 on 89 cardiac patients showed 
that all MacNew heart disease health-related 
quality of life questionnaire (MacNew) and SF-
36 domains show significant improvements 
except the SF-36 domain for emotional 
limitation. Moholdt el at.19 compared 4 weeks 
of residential with home-based CR program. 

Figure Average Score of QoL Dimensions in 11 Patients with Coronary Artery Disease

Ina Marita, Sunaryo B. Sastradimaja, Badai Bhatara Tiksnadi: Effect of Short Term Cardiac Rehabilitation 
Program on Quality of Life in Patients with Coronary Artery Disease



Althea Medical Journal. 2017;4(3)

484     AMJ September 2017

They found that there is a significant increase 
in social and physical domains of the MacNew 
questionnaire in both groups, but not the 
emotional domain.19

Possible explanations of QoL improvement 
in the CR program are that the program may 
ameliorate subject’s risk factors and lifestyle 
by education and also increase in exercise 
capacity by gradual exercise loading, resulting 
in improvement of their performance and 
a better QOL.12 Improved physical status of 
patients also influences on their psychological 
condition and increases participation in 
social activities along with an improved well 
being throughout.3 Recent studies showed 
that home- and supervised -based cardiac 
rehabilitation have the same effectiveness 
in improving the QoL in patients with CAD, 
myocardial infarction, and patients who 
underwent revascularization.4,20 In this study, 
cardiac rehabilitation was performed in a 
short period of time, but the subjects were 
not only encouraged to undergo supervised 
cardiac rehabilitation at the hospital twice a 
week, but also underwent home-based cardiac 
rehabilitation three times a week. Thus, if 
the patient underwent CR program regularly, 
it may have a major impact in improving the 
patient’s QoL. In addition, CR programs held 
at Dr. Hasan Sadikin General Hospital already 
has a good multidiciplinary team coordination 
whereby the outcome of rehabilitation 
programs is fairly outstanding.

Limitation of this study is that the absence 
of female study subjects which results in 
the findings of this study cannot be used to 
describe the effects of cardiac rehabilitation 
on quality of life in the whole population.

Based on the results of this study, it 
can be deduced that short term cardiac 
rehabilitation program can improve physical 
and mental health components in patients 
with coronary artery disease. This study is 
expected to be able to enhance the active 
participation of physicians and other health 
providers to motivate patients to undergo 
cardiac rehabilitation in accordance with the 
gold standards to increase the CAD patient’s 
participation. We also hope this study will be a 
guide that optimal result can be obtained with 
cardiac rehabilitation program within a shorter 
period, however, patients must be observed that 
they did a proper and regular rehabilitation in 
hospital as well as at their home. To get better 
study results in future studies, using specific 
quality of life questionnaire for heart disease 
is recommended, such as the seattle angina 
questionnaire (SAQ), along with a generic 

questionnaire. Routine follow ups with a 
longer period of time can also be performed 
to determine long-term effects of cardiac 
rehabilitation on quality of life. Moreover, 
further studies should be conducted not only 
to assess the subjective quality of life but also 
the objectivity by measuring the capacity of 
exercises. 

 
References

1. WHO. Global status report on 
noncommunicable diseases 2014. Geneva: 
World Health Organization; 2014.

2. Hamm CW, Bassand J-P, Agewall S, Bax J, 
Boersma E, Bueno H, et al. ESC Guidelines 
for the management of acute coronary 
syndromes in patients presenting without 
persistent ST-segment elevation. Eur Heart 
J. 2011;32(23):2999–3054.

3. Saeidi M, Mostafavi S. GW24-e3978 Effects 
of a comprehensive cardiac rehabilitation 
program on quality of life in patients 
with coronary artery disease. Heart. 
2013;99(Suppl 3):A140–1.

4. Taylor RS, Dalal H, Jolly K, Moxham T, 
Zawada A. Home-based versus centre-
based cardiac rehabilitation. Cochrane 
Database Syst Rev. 2010;1(1):5631–45.

5. Dyer MT, Goldsmith KA, Sharples LS, Buxton 
MJ. A review of health utilities using the 
EQ-5D in studies of cardiovascular disease. 
Health Qual Life Outcomes. 2010;8(13):1–
12.

6. Shepherd CW, While AE. Cardiac 
rehabilitation and quality of life: a 
systematic review. Int J Nurs Stud. 
2012;49(6):755–71. 

7. RAND Health. Scoring Instructions for the 
36-Item Short Form Survey (SF-36). RAND; 
2009 [cited 2016 January 14] Available 
from: http://www.rand.org/health/
surveys_tools/mos/mos_core_36item.
html.

8. Jenni J, Buckley J, Furze G, Doherty P, Speck 
L, Connolly S, et al. The BACPR standards 
and core components for cardiovascular 
prevention and rehabilitation 2012. 2nd 
ed. London: BACPR; 2012.

9. Turk-Adawi KI, Grace SL. Narrative review 
comparing the benefits of and participation 
in cardiac rehabilitation in high-, middle-
and low-income countries. Heart Lung 
Circ. 2015;24(5):510–20.

10. Samayoa L, Grace SL, Gravely S, Scott LB, 
Marzolini S, Colella TJ. Sex differences in 
cardiac rehabilitation enrollment: a meta-
analysis. Can J Cardiol. 2014;30(7):793–



Althea Medical Journal. 2017;4(3)

485

800.
11. Freitas PD, Haida A, Bousquet M, Richard 

L, Mauriège P, Guiraud T. Short-term 
impact of a 4-week intensive cardiac 
rehabilitation program on quality of life 
and anxiety-depression. Ann Phys Rehabil 
Med. 2011;54(3):132–43.

12. Lee YH, Hur SH, Sohn J, Lee HM, Park 
NH, Cho YK, et al. Impact of home-based 
exercise training with wireless monitoring 
on patients with acute coronary 
syndrome undergoing percutaneous 
coronary intervention. J Korean Med Sci. 
2013;28(4):564–8.

13. Tavella R, Beltrame JF. Cardiac rehabilitation 
may not provide a quality of life benefit 
in coronary artery disease patients. BMC 
Health Serv Res. 2012;12(1):406–14.

14. Fletcher GF, Ades PA, Kligfield P, Arena 
R, Balady GJ, Bittner VA, et al. Exercise 
standards for testing and training. 
Circulation. 2013;128(8):873–934.

15. Poortaghi S, Baghernia A, Golzari SE, 
Safayian A, Atri SB. The effect of home-
based cardiac rehabilitation program on 
self efficacy of patients referred to cardiac 
rehabilitation center. BMC Res Notes. 
2013;6(1):287–90.

16. Hazavei SMM, Sabzmakan L, Hasanzadeh 
A, Rabiei K, Roohafza H. The effects of an 

educational program based on precede 
model on depression levels in patients 
with coronary artery bypass grafting. 
ARYA Atheroscler. 2012;8(1):36–42.

17. Sharif F, Shoul A, Janati M, Kojuri J, Zare 
N. The effect of cardiac rehabilitation 
on anxiety and depression in patients 
undergoing cardiac bypass graft 
surgery in Iran. BMC Cardiovasc Disord. 
2012;12(1):40–6.

18. Weberg M, Hjermstad M, Hilmarsen C, 
Oldervoll L. Inpatient cardiac rehabilitation 
and changes in self-reported health related 
quality of life–a pilot study. Ann Phys 
Rehabil Med. 2013;56(5):342–55.

19. Moholdt T, Bekken Vold M, Grimsmo 
J, Slordahl SA, Wisloff U. Home-based 
aerobic interval training improves peak 
oxygen uptake equal to residential cardiac 
rehabilitation: a randomized, controlled 
trial. PloS one. 2012;7(7):e41199–203.

20. Oerkild B, Frederiksen M, Hansen JF, 
Simonsen L, Skovgaard LT, Prescott E. 
Home-based cardiac rehabilitation is 
as effective as centre-based cardiac 
rehabilitation among elderly with coronary 
heart disease: results from a randomised 
clinical trial. Age Ageing. 2011;40(1):78–
85.

Ina Marita, Sunaryo B. Sastradimaja, Badai Bhatara Tiksnadi: Effect of Short Term Cardiac Rehabilitation 
Program on Quality of Life in Patients with Coronary Artery Disease