Original research| Volume 101, ISSUE 4, P650-657, April 2020

Association Between Exercise Capacity and Health-Related Quality of Life During and After Cardiac Rehabilitation in Acute Coronary Syndrome Patients: A Substudy of the OPTICARE Randomized Controlled Trial

Published:January 02, 2020DOI:


      • Cardiac rehabilitation (CR) results in improvement in exercise capacity and health-related quality of life (HRQOL).
      • The improvements in exercise capacity and HRQOL persist during long-term follow-up.
      • Exercise capacity and the global and physical aspect of quality of life are weakly associated.
      • The association between exercise capacity and HRQOL is independent of timing relative to CR.



      To examine the strength of the association between exercise capacity and health-related quality of life (HRQOL) during and after cardiac rehabilitation (CR) in patients with acute coronary syndrome (ACS) who completed CR.


      Prospective cohort study.


      Outpatient CR center.


      Patients (N=607) with ACS who completed CR.


      Multidisciplinary 12-week exercise-based CR program.

      Main Outcome Measures

      At baseline (pre-CR), the 6-Minute Walk Test (6MWT) was performed to determine exercise capacity, and the MacNew Heart Disease Health-related Quality of Life questionnaire was used to assess HRQOL. Measurements were repeated immediately after completion of CR (post-CR): at 12 months and 18 months follow-up. Multivariable linear regression, including an interaction term for time and exercise capacity, was applied to study the association between exercise capacity and HRQOL at different time points relative to CR, whereas model parameters were estimated by methods that accounted for dependency of repeated observations within individuals.


      Mean age in years ± SD was 58±8.9 and 82% of participants were male. Baseline mean 6MWT distance in meters ± SD was 563±77 and median (25th-75th percentile) global HRQOL was 5.5 (4.6-6.1) points. Mean 6MWT distance (P<.001) and the global (P<.001), physical (P<.001), emotional (P<.001) and social (P<.001) domains of HRQOL improved significantly during CR and continued to improve during follow-up post-CR. Independent of the timing relative to CR (ie, pre-CR, post-CR, or during follow-up), a difference of 10 m 6MWT distance was associated with a mean difference in the global HRQOL domain of 0.007 (95% confidence interval [CI], 0.001-0.014) points (P=.029) and a mean difference in the physical domain of 0.009 (95% CI, 0.001-0.017) points (P=.023).


      Better exercise capacity was significantly associated with higher scores on the global and physical domains of HRQOL, irrespective of the timing relative to CR, albeit these associations were weak. Hence, CR programs in secondary prevention should continue to aim at enhancing both HRQOL and exercise capacity.


      List of abbreviations:

      6MWT (6-Minute Walk Test), ACS (acute coronary syndrome), CABG (coronary artery bypass graft), CAD (coronary artery disease), CI (confidence interval), CR (cardiac rehabilitation), CVD (cardiovascular disease), HRQOL (health-related quality of life), OPTICARE (Optimal Cardiac Rehabilitation), RCT (randomized controlled trial)
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        • National Institutes of Health
        Morbidity & mortality: 2012 chart book on cardiovascular, lung, and blood diseases.
        (Available at:)
        • Roger V.L.
        • Go A.S.
        • Lloyd-Jones D.M.
        • et al.
        Heart disease and stroke statistics--2011 update: a report from the American Heart Association.
        Circulation. 2011; 123: e18-209
        • Zhao Z.
        • Winget M.
        Economic burden of illness of acute coronary syndromes: medical and productivity costs.
        BMC Health Serv Res. 2011; 11: 35
        • Briffa T.G.
        • Hobbs M.S.
        • Tonkin A.
        • et al.
        Population trends of recurrent coronary heart disease event rates remain high.
        Circ Cardiovasc Qual Outcomes. 2011; 4: 107-113
        • Shetty S.
        • Halpern R.
        • McCollam P.L.
        Cost of care for new versus recurrent acute coronary syndrome patients.
        J Med Econ. 2008; 11: 81-99
        • National Institute for Health and Care Excellence
        Secondary prevention after a myocardial infarction.
        (Available at:)
        Date accessed: October 12, 2019
        • Piepoli M.F.
        • Corra U.
        • Adamopoulos S.
        • et al.
        • Secondary prevention in the clinical management of patients with cardiovascular diseases
        Core components, standards and outcome measures for referral and delivery: a policy statement from the cardiac rehabilitation section of the European Association for Cardiovascular Prevention & Rehabilitation. Endorsed by the Committee for Practice Guidelines of the European Society of Cardiology.
        Eur J Prev Cardiol. 2014; 21: 664-681
        • Lam G.
        • Snow R.
        • Shaffer L.
        • Londe M.L.
        • Spencer K.
        • Caulin-Glaser T.
        The effect of a comprehensive cardiac rehabilitation program on 60-day hospital readmissions after an acute myocardial infarction.
        J Am Coll Cardiol. 2011; 57: E597
        • Heran B.S.
        • Chen J.M.
        • Ebrahim S.
        • et al.
        Exercise-based cardiac rehabilitation for coronary heart disease.
        Cochrane Database Syst Rev. 2011; 7: CD001800
        • Lawler P.R.
        • Filion K.B.
        • Eisenberg M.J.
        Efficacy of exercise-based cardiac rehabilitation post-myocardial infarction: a systematic review and meta-analysis of randomized controlled trials.
        Am Heart J. 2011; 162: 571-584
        • Ades P.A.
        Cardiac rehabilitation and secondary prevention of coronary heart disease.
        N Engl J Med. 2001; 345: 892-902
        • Lavie C.J.
        • Milani R.V.
        Cardiac rehabilitation and exercise training in secondary coronary heart disease prevention.
        Prog Cardiovasc Dis. 2011; 53: 397-403
        • Dugmore L.D.
        • Tipson R.J.
        • Phillips M.H.
        • et al.
        Changes in cardiorespiratory fitness, psychological wellbeing, quality of life, and vocational status following a 12 month cardiac exercise rehabilitation programme.
        Heart. 1999; 81: 359-366
        • Francis T.
        • Kabboul N.
        • Rac V.
        • et al.
        The effect of cardiac rehabilitation on health-related quality of life in patients with coronary artery disease: a meta-analysis.
        Can J Cardiol. 2019; 35: 352-364
        • Pragodpol P.
        • Ryan C.
        Critical review of factors predicting health-related quality of life in newly diagnosed coronary artery disease patients.
        J Cardiovasc Nurs. 2013; 28: 277-284
        • Chen C.H.
        • Chen Y.J.
        • Tu H.P.
        • Huang M.H.
        • Jhong J.H.
        • Lin K.L.
        Benefits of exercise training and the correlation between aerobic capacity and functional outcomes and quality of life in elderly patients with coronary artery disease.
        Kaohsiung J Med Sci. 2014; 30: 521-530
        • Staniute M.
        • Bunevicius A.
        • Brozaitiene J.
        • Bunevicius R.
        Relationship of health-related quality of life with fatigue and exercise capacity in patients with coronary artery disease.
        Eur J Cardiovasc Nurs. 2014; 13: 338-344
        • Strong P.C.
        • Lee S.H.
        • Chou Y.C.
        • Wu M.J.
        • Hung S.Y.
        • Chou C.L.
        Relationship between quality of life and aerobic capacity of patients entering phase II cardiac rehabilitation after coronary artery bypass graft surgery.
        J Chin Med Assoc. 2012; 75: 121-126
        • Bunevicius A.
        • Stankus A.
        • Brozaitiene J.
        • Girdler S.S.
        • Bunevicius R.
        Relationship of fatigue and exercise capacity with emotional and physical state in patients with coronary artery disease admitted for rehabilitation program.
        Am Heart J. 2011; 162: 310-316
        • Sunamura M.
        • Ter Hoeve N.
        • van den Berg-Emons H.J.
        • et al.
        OPTImal CArdiac REhabilitation (OPTICARE) following acute coronary syndromes: rationale and design of a randomised, controlled trial to investigate the benefits of expanded educational and behavioural intervention programs.
        Neth Heart J. 2013; 21: 324-330
        • Kemps H.M.
        • van Engen-Verheul M.M.
        • Kraaijenhagen R.A.
        • et al.
        Improving guideline adherence for cardiac rehabilitation in the Netherlands.
        Neth Heart J. 2011; 19: 285-289
        • van Engen-Verheul M.M.
        • Kemps H.M.
        • de Keizer N.F.
        • et al.
        Revision of the Dutch clinical algorithm for assessing patient needs in cardiac rehabilitation based on identified implementation problems.
        Eur J Prev Cardiol. 2012; 19: 504-514
        • Doyle F.
        • McGee H.M.
        • De La Harpe D.
        • Shelley E.
        • Conroy R.
        The Hospital Anxiety and Depression Scale depression subscale, but not the Beck Depression Inventory-Fast Scale, identifies patients with acute coronary syndrome at elevated risk of 1-year mortality.
        J Psychosom Res. 2006; 60: 461-467
        • Stafford L.
        • Berk M.
        • Jackson H.J.
        Validity of the Hospital Anxiety and Depression Scale and Patient Health Questionnaire-9 to screen for depression in patients with coronary artery disease.
        Gen Hosp Psychiatry. 2007; 29: 417-424
        • De Gucht V.
        • Van Elderen T.
        • van der Kamp L.
        • Oldridge N.
        Quality of life after myocardial infarction: translation and validation of the MacNew Questionnaire for a Dutch population.
        Qual Life Res. 2004; 13: 1483-1488
        • Dixon T.
        • Lim L.L.
        • Oldridge N.B.
        The MacNew heart disease health-related quality of life instrument: reference data for users.
        Qual Life Res. 2002; 11: 173-183
        • ATS Committee on Proficiency Standards for Clinical Pulmonary Function Laboratories
        ATS statement: guidelines for the six-minute walk test.
        Am J Respir Crit Care Med. 2002; 166: 111-117
        • Bellet R.N.
        • Adams L.
        • Morris N.R.
        The 6-minute walk test in outpatient cardiac rehabilitation: validity, reliability and responsiveness--a systematic review.
        Physiotherapy. 2012; 98: 277-286
        • Gremeaux V.
        • Troisgros O.
        • Benaim S.
        • et al.
        Determining the minimal clinically important difference for the six-minute walk test and the 200-meter fast-walk test during cardiac rehabilitation program in coronary artery disease patients after acute coronary syndrome.
        Arch Phys Med Rehabil. 2011; 92: 611-619
        • Twisk J.W.R.
        Applied longitudinal data analysis for epidemiology: a practical guide.
        Cambridge University Press, New York2013
        • Nogueira I.D.
        • Servantes D.M.
        • Nogueira P.A.
        • et al.
        Correlation between quality of life and functional capacity in cardiac failure.
        Arq Bras Cardiol. 2010; 95: 238-243
        • Verrill D.E.
        • Barton C.
        • Beasley W.
        • Lippard M.
        • King C.N.
        Six-minute walk performance and quality of life comparisons in North Carolina cardiac rehabilitation programs.
        Heart Lung. 2003; 32: 41-51
        • Dickens C.
        • Cherrington A.
        • McGowan L.
        Depression and health-related quality of life in people with coronary heart disease: a systematic review.
        Eur J Cardiovasc Nurs. 2012; 11: 265-275
        • Duenas M.
        • Ramirez C.
        • Arana R.
        • Failde I.
        Gender differences and determinants of health related quality of life in coronary patients: a follow-up study.
        BMC Cardiovasc Disord. 2011; 11: 24
        • Fiorina C.
        • Vizzardi E.
        • Lorusso R.
        • et al.
        The 6-min walking test early after cardiac surgery. Reference values and the effects of rehabilitation programme.
        Eur J Cardiothorac Surg. 2007; 32: 724-729
        • Oldridge N.B.
        • Pakosh M.T.
        • Thomas R.J.
        Cardiac rehabilitation in low- and middle-income countries: a review on cost and cost-effectiveness.
        Int Health. 2016; 8: 77-82
        • Doll J.A.
        • Hellkamp A.
        • Thomas L.
        • et al.
        Effectiveness of cardiac rehabilitation among older patients after acute myocardial infarction.
        Am Heart J. 2015; 170: 855-864
        • Yang X.
        • Li Y.
        • Ren X.
        • et al.
        Effects of exercise-based cardiac rehabilitation in patients after percutaneous coronary intervention: a meta-analysis of randomized controlled trials.
        Sci Rep. 2017; 7: 44789
        • Yohannes A.M.
        • Doherty P.
        • Bundy C.
        • Yalfani A.
        The long-term benefits of cardiac rehabilitation on depression, anxiety, physical activity and quality of life.
        J Clin Nurs. 2010; 19: 2806-2813
        • Gupta R.
        • Sanderson B.K.
        • Bittner V.
        Outcomes at one-year follow-up of women and men with coronary artery disease discharged from cardiac rehabilitation: what benefits are maintained?.
        J Cardiopulm Rehabil Prev. 2007; 27 (quiz 9-20): 11-18
        • Boesch C.
        • Myers J.
        • Habersaat A.
        • Ilarraza H.
        • Kottman W.
        • Dubach P.
        Maintenance of exercise capacity and physical activity patterns 2 years after cardiac rehabilitation.
        J Cardiopulm Rehabil. 2005; 25 (quiz 2-3): 14-21
        • Sunamura M.
        • Ter Hoeve N.
        • Geleijnse M.L.
        • et al.
        Cardiac rehabilitation in patients who underwent primary percutaneous coronary intervention for acute myocardial infarction: determinants of programme participation and completion.
        Neth Heart J. 2017; 25: 618-628
        • 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: A4919