Secondary Logo

Journal Logo

ARTICLES: Innovative Interventions

Home-Based Versus Outpatient-Based Cardiac Rehabilitation Post–Coronary Artery Bypass Graft Surgery

A Randomized Controlled Trial

Takroni, Mohammed A. PhD; Thow, Morag PhD; Ellis, Brian PhD; Seenan, Christopher PhD

Author Information
The Journal of Cardiovascular Nursing: 5/6 2022 - Volume 37 - Issue 3 - p 274-280
doi: 10.1097/JCN.0000000000000763
  • Free

Abstract

Coronary heart disease (CHD) is the most common cause of death from cardiovascular disease (CVD), which is the leading cause of mortality worldwide.1 Coronary heart disease is the major cause of mortality in the Kingdom of Saudi Arabia (KSA), which is facing an alarming increase in death rates from CVD and a predicted increased burden of CVD.2,3 It has been reported that 26% of total deaths in the KSA were attributed to CVDs (27% of deaths in men and 23.5% of deaths in women).3 At the present time, in the KSA, there is no provision for outpatient-based cardiac rehabilitation. Outpatient cardiac rehabilitation is normal practice for modern comprehensive cardiac care worldwide.4 Importantly, no research has been published that investigates the effect of outpatient-based cardiac rehabilitation in the Gulf Council Countries, including the KSA. Most of the research that has been conducted on the potential benefits of cardiac rehabilitation has been carried out in non-Arabic countries primarily in western healthcare systems.5–10

When evaluated, home-based cardiac rehabilitation has been found to be as effective as outpatient cardiac rehabilitation and some additional benefits of home-based cardiac rehabilitation have been reported.5 One key limitation of previous studies has been the lack of follow-up after the intervention period. Therefore, it is unknown whether the benefits gained through participation in outpatient-based or home-based cardiac rehabilitation are maintained. Thus, there is a need to address this gap in the literature and specifically in a Saudi population. The aim of this study was to assess the effectiveness of an 8-week home-based cardiac rehabilitation program using individualized exercise prescription at home (home-based cardiac rehabilitation) and an outpatient-based cardiac rehabilitation program (outpatient-based cardiac rehabilitation) compared with usual care (control group) for people with CHD after coronary artery bypass graft surgery.

Methods

Design

This was a 3-arm, single-blind randomized controlled trial conducted at the King Faisal Heart Institute, within the King Faisal Specialist Hospital Riyadh, Saudi Arabia.

Participants

Patients 4 to 6 weeks post–coronary artery bypass graft surgery who completed inpatient cardiac rehabilitation at King Faisal Specialist Hospital and Research Centre were invited to take part in the study. Patients post–coronary artery bypass graft surgery were chosen for this study with the aim of recruiting a relatively homogeneous sample, thus facilitating clear comparison of the effects of the interventions.

Participants were eligible if they were clinically stable as defined by the American College of Cardiology/American Heart Association.11 Only participants stratified as low to moderate risk as identified by the American College of Sport Medicine12 were included. Participants were excluded from this study if they were pregnant, had an ejection fraction of less than 40% at rest (high risk as defined by American Association of Cardiovascular and Pulmonary Rehabilitation Stratification),13 were diagnosed with mental health disorders (such as anxiety or depression), or had any vision or hearing defects or any neurological, respiratory, or musculoskeletal conditions that have an impact on ambulation.

Sample Size

Sample size was estimated using a minimal difference in the incremental shuttle walk test (ISWT) between the 2 groups of 50 m.14 Power analysis was set at 90% at an α level of P < .05; GPower (© 2020 Heinrich Heine University Düsseldorf) calculation program15 was used to calculate sample size, which indicated that 28 participants were required in each group.

Ethical Approval

Ethical approval for this study was obtained from the King Faisal Specialist Hospital and Research Centre in Saudi Arabia (ORA/1022/34). Patients who met the inclusion criteria and agreed to be enrolled in this study were randomly allocated to the 3 groups using consecutive sampling methods.16 Each eligible participant was asked to pick a paper from a box, which included the name of 1 of 3 groups: home-based cardiac rehabilitation, outpatient-based cardiac rehabilitation, or usual care (control). Study recruitment occurred during 2015 and 2016. A cardiopulmonary physiotherapist met with all eligible patients after surgery. The study was explained in depth and all potential participants were provided with an information sheet. After at least 24 hours to consider the information provided and seek answers to any questions, potential participants were contacted again and asked to sign an informed consent form if they wished to participate.

Outcome Measures

Participant outcome measurements were recorded at baseline, at postintervention, and at a 4-week follow-up. All measures were recorded by a cardiopulmonary rehabilitation physiotherapist who was blinded to participant allocation. The outcome measures were physical function and physiological and psychological status. Physical function was assessed using the ISWT following the original standardized instructions as recommended by the American College of Sports Medicine.17 The ISWT is an externally paced incremental walking test, with each shuttle covering a distance of 10 m.18

The physiological variable was metabolic equivalents (METs), which are obtained from the ISWT. The ISWT data were transferred to METs using the American College of Sports Medicine protocol based on the level and number of shuttles (American College of Sports Medicine, 2005).19 The ISWT predicted energy expenditure was converted into METs to represents a simple, practical, and easily understood concept with which to express the energy cost of physical activities as a multiple of the resting metabolic rate.20 Metabolic equivalents are commonly used by clinicians to express resting metabolic rate and to express and compare different levels of exertion.

The psychological variables were anxiety and depression, assessed using the Arabic version of the Hospital Anxiety and Depression Scale (HADS).21 The HADS consists of 14 items, divided into two 7-item subscales for anxiety (HADS-A) and depression (HADS-D).22 Scoring for each item ranges from 0 to 3, with 3 denoting the highest anxiety or depression level. A total subscale score of higher than 8 points of a possible 21 denotes considerable symptoms of anxiety or depression.22

Physical function, mental status, and quality of life were assessed using the Arabic version of the 36-item Short Form Health Survey (SF-36) questionnaire 24. The SF-36 contains 8 domains to evaluate health-related function which reflects perception of general symptoms. The SF-36 includes 8 scales: (1) physical functioning, (2) role physical, (3) bodily pain, (4) general health, (5) vitality, (6) social functioning, (7) role emotional, and (8) mental health. The SF-36 produces 2 composite scores, the physical component summary score and mental component summary score, used in this study.23 The Arabic versions of SF-3624 and HADS21 have been shown to be valid and reliable in evaluating the impact of symptoms after coronary artery bypass graft surgery. These versions of the HADS and SF-36 have been found to be reliable and valid (HADS25: reliability, 0.8 and validity, 0.90 and SF-3626: reliability, 0.85 and validity, 0.92).

Interventions

The outpatient-based cardiac rehabilitation group completed a supervised cardiac rehabilitation program 3 times a week for 8 weeks. Each session included 15 minutes of warm-up exercises, 20 minutes of progressive aerobic exercises (10 stations and active recovery [AR] exercises that allow the participant to work at a slightly lower intensity within their training zone), and 10 minutes of cool-down exercises (Table 1).27 Participants wore Polar (Polar, United Kingdom) watches (Polar FT-80) to detect the target heart rate. All participants in the intervention groups were provided with the same polar watch and instructions on how to use it correctly, in addition to training on how to do the exercises and monitor their intensity before, during, and after exercises, by the cardiopulmonary physiotherapist.

TABLE 1 - Cardiovascular and Active Recovery Exercises Included in the 10 Stations
Cardiovascular Exercises Active Recovery Exercises
March on the spot Biceps curls
Step ups Upright rowing
Heels digs Shoulder Lateral rises
Lunges back Front raises
Sit to stand Wall presses
Knee lifts Body side bending
Star jumping Squatting
Shuttle walking Standing dumbbell rowing
Step kicks Diagonal arm reaches
Toe tap to front Butterfly (pectoral)

The home-based cardiac rehabilitation intervention was supported by use of the Physiotools (Tampere, Finland). Physiotools is a professional exercise software package that includes a library of exercises appropriate for cardiovascular (CV) rehabilitation.28 Participants in the home-based cardiac rehabilitation group were provided with a data sheet to record their exercise, a color-coded printed file of Physiotools home exercise program, and a Polar watch. They also received a weekly telephone call to answer any questions and give the required support, such as encouragement, to continue with the exercise program.

The aerobic exercise program for both groups was divided into 3 levels. For the first 2 weeks, participants were asked to do 10 minutes of CV and 10 minutes of AR exercise. Then, in the third and fourth weeks, they gradually progressed to 15 minutes of CV and 5 minutes of AR. From the fifth to eighth weeks, the participants were asked to do 20 minutes of CV and no AR. The duration of each station was 2 minutes at week 8. The intensity of the exercise program was gradually elevated to enable the participants to attain 2 continuous minutes of CV exercises and to maintain the target heart rate of 60% to 70% maximum heart rate and the desired Borg scale level (12–15).27 More details about the exercise for the 2 intervention groups are displayed in Table 2.29

TABLE 2 - Intervention Parameters for Each Group27
Intervention Parameters Outpatient CR Group Home CR Group
Frequency 3 times/week 3 times/week
Intensity Moderate Moderate
Type RPE, 12–14
60%–75% HRmax
Borg scale <15
Circuit training aerobic exercise of 10 stations
RPE, 12–14
60%–75% HRmax
Borg scale <15
Circuit training aerobic exercise of 10 stations
Time 45 min (15 min warm-up, 20 min aerobic exercise, and 10 min cool down). 45 min (15 min warm-up, 20 min aerobic exercise using Physiotools, and 10 min cool down)
Setting King Faisal Heart Institute, Physiotherapy Gymnasium, KSA, Riyadh Patient's own home
Who Cardiopulmonary rehabilitation specialist (physiotherapist) Cardiopulmonary rehabilitation specialist (physiotherapist)
Motivation From physiotherapist Telephone calls and self-motivation
Abbreviations: CR, cardiac rehabilitation; HR, heart rate; HRmax: maximum heart rate; RPE, rate of perceived exertion.

The control group had no intervention program. Based on current standard practice, all participants were given an instruction booklet that contains instructions and precautions about surgery, wound care and encouragement to be active.

Statistical Analysis

Statistical analysis was conducted using SPSS (version 20.0; IBM, Armonk, New York). All data were normally distributed. Repeated-measures analysis of variance was used to compare all measures preintervention and postintervention. A 1-way repeated-measure between-group analysis of variance, with Tukey honestly significant differences post hoc test, was conducted to analyze the changes in the outcome measures at baseline, at postintervention, and at the 4-week follow-up. The significance level was set at P < .05 for between group analyses and data are presented as mean ± SD unless stated otherwise.

Results

A total of 82 participants consented to participate in the study and were randomized (Figure 1). Of those, 73 completed the study and were included in the analysis. The only differences between the groups at baseline were age and HADS scores. The mean age of the home-based cardiac rehabilitation group was greater than that of the outpatient-based cardiac rehabilitation groups, and HAD-A and -D scores were greater in the outpatient-based cardiac rehabilitation group than the home-based cardiac rehabilitation group (Table 3).

F1
FIGURE 1:
Study flow chart. Outpatient indicates outpatient-based cardiac rehabilitation; Home, home-based cardiac rehabilitation.
TABLE 3 - Demographic Data and Outcome Measures at Baseline
Outpatient-Based CR Home-Based CR Control P
Gender (male:female ratio) 20:5 20:4 19:5 >.05
Age, y 54 (7.51) 57 (7.71) 55 (6.81) <.05
ISWT, m 398 (53.0) 382.92 (50.5) 379.58 (52.0) .400
METs, mL/kg/min 4.6 (4.3) 4.5 (4.3) 4.5 (4.3) >.05
HADS-A 8.92 (0.76) 8.25 (1.07) 8.66 (0.64) .024
HADS-D 8.24 (4.3) 7.46 (4.3) 7.29 (4.4) .001
SF-36 physical component summary score 32.55 (4.53) 30.69 (4.42) 31.94 (4.88) >.05
SF-36 mental component summary score 29.25 (4.17) 29.40 (4.54) 30.08 (4.70) >.05
Data are presented as mean (SD).
Abbreviations: CR, cardiac rehabilitation; HADS-A, Hospital Anxiety and Depression Scale–Anxiety; HADS-D, Hospital Anxiety and Depression Scale–Depression; ISWT, incremental shuttle walk test; METs, metabolic equivalents; SF-36, 36-item Short Form Health Survey.

Table 4 shows outcome the measures postintervention and post–4-week follow-up. Postintervention, mean ISWT distance was greater in both intervention groups compared with baseline. Mean distance increased by 71 ± 9.19 m in the outpatient-based cardiac rehabilitation group (P = .001) and by 66 ± 0.58 m in the home-based cardiac rehabilitation group (P = .001). The ISWT distance covered by the control group did not change over the period of intervention. No statistically significant differences were found between the 2 intervention groups (P > .05; Figure 2). There was also a statistically significant increase in the mean score of METs in both intervention groups postintervention (P = .001).

TABLE 4 - Outcome Measures After the Intervention and After the 4-Week Follow-up Period
After the CR Intervention After the 4-wk Follow-up
Outpatient-Based CR Home-Based CR Control P Outpatient-Based CR Home-Based CR Control P
ISWT, m 469.2 (62.18) 448.75 (50.58) 382.91 (53.39) .001 442.8 (62.55) 470.8 (45.34) 383.75 (54.36) .001
METs, mL/kg/min 5.1 (0.57) 4.9 (0.48) 4.5 (0.47) .001 4.9 (0.55) 5.1 (0.35) 4.5 (0.50) .001
HADS-A 4.92 (0.86) 5.95 (1.23) 6.70 (0.62) .001 4.72 (0.79) 3.50 (0.89) 6.66 (0.58) .001
HADS-D 4.32 (0.75) 4.88 (0.99) 5.08 (1.13) .021 4.12 (0.73) 3.79 (0.72) 5.4 (0.71) .001
SF-36 physical component score 41.75 (4.47) 36.98 (4.34) 34.02 (4.43) .001 40.54 (4.46) 41.04 (4.47) 34.06 (4.75) .001
SF-36 mental component score 40.42 (4.40) 35.78 (4.24) 32.83 (4.50) .001 38.30 (4.41) 38.74 (4.23) 32.50 (4.92) .001
Data are presented as mean (SD). Analyses of variance were used and P value representing the between group differences for the intervention groups.
Abbreviations: CR, cardiac rehabilitation; HADS-A, Hospital Anxiety and Depression Scale–Anxiety; HADS-D, Hospital Anxiety and Depression Scale–Depression; ISWT, incremental shuttle walk test; METs, metabolic equivalents; SF-36, 36-item Short Form Health Survey.

F2
FIGURE 2:
The mean incremental shuttle walk test distance in meters for the 3 groups across time. Outpatient indicates outpatient-based cardiac rehabilitation; Home, home-based cardiac rehabilitation.

At the 4-week follow-up, the mean ISWT distance increased again in the home-based cardiac rehabilitation group (470.42 ± 54.36 m; P = .001) and was significantly greater than in the outpatient-based cardiac rehabilitation group, which showed a decrease in the ISWT distance from postintervention (442.80 ± 62.80 m; P = .001). However, both intervention groups had higher mean ISWT distance compared with the control group, which showed no change (383.36 ± 54.36 m; P > .05). A similar pattern of outcomes was found for mean METs scores (Figure 3) (Table 4).

F3
FIGURE 3:
The mean value of metabolic equivalents for the 3 groups across time. Outpatient indicates outpatient-based cardiac rehabilitation; Home, home-based cardiac rehabilitation.

Both intervention groups also showed similar levels of improvement in psychological status postintervention, measured using the HADS-A and HADS-D, and in physical and mental components of the SF-36 (Table 4). This improvement was maintained by the home-based cardiac rehabilitation group at the 4-week follow-up (Table 4).

Discussion

The main findings of this study were that both an 8-week home-based and an outpatient-based cardiac rehabilitation intervention increased physical function in patients after coronary artery bypass graft. In addition, both interventions resulted in similar levels of improvement in psychological status and quality of life postintervention. At the 4-week follow-up, the outpatient-based cardiac rehabilitation group reported significant improvement compared with baseline in all outcome measures, but the home-based cardiac rehabilitation group showed greater improvement. There were no adverse events during the intervention period and there was high adherence to the interventions.

The findings of this study are consistent with existing literature, in confirming that home-based cardiac rehabilitation is as effective as outpatient-based cardiac rehabilitation for patients post–coronary artery bypass graft surgery. Previous studies used interventions with durations of 8 weeks8 and 6 weeks6; however, all results were consistent with those found in the present study. In the current study, the ISWT distance covered by both the outpatient-based cardiac rehabilitation and home-based cardiac rehabilitation groups increased postintervention. The mean improvement in ISWT distance of the outpatient and home groups (71.2 and 65.75 m, respectively) is regarded as clinically significant as it is between the currently quoted minimally clinically important difference of 50 to 70 m.14,30 The similarity in levels of improvement could be because of the similar nature of the home and outpatient exercise programs provided for both intervention groups. Even though the outpatient-based cardiac rehabilitation group exercised under supervision, the home-based cardiac rehabilitation group was equally effective without direct supervision. Participants in the home-based cardiac rehabilitation group maintained participation by following the logbook and engaging in weekly telephone calls to have their questions answered and receive reassurance from the cardiopulmonary team who was available also to provide medical care.

The improvements seen in the home-based cardiac rehabilitation group at the 4-week follow-up may have been the result of an increased internal locus of control, which can inspire positive behaviors.31 The outpatient-based group was directed and led by the cardiac rehabilitation physiotherapist during the exercise class, and were possibly less likely to develop an internal locus of control. A future study could include behavior change intervention to measure motivation and long-term exercise behavior for those who engage in outpatient-based cardiac rehabilitation.

Compliance with the exercise program among participants in both the outpatient-based cardiac rehabilitation and home-based cardiac rehabilitation groups was high (91.7% and 87.5%, respectively). This may have been a factor that contributed to the continuation of statistically significant improvement in the ISWT and other outcome measures of the home-based cardiac rehabilitation group at the 4-week follow-up.

Our findings are consistent with a study by Pourafkari et al,32 where their demographics are comparable with those in the current study in relation to male/female ratio, type of surgery, and average age. They demonstrated that engagement with a program of cardiac rehabilitation decreased levels of anxiety and depression after coronary artery bypass graft surgery. The results of the current study are similar in that both intervention groups demonstrated a reduction in anxiety and depression levels after 8 weeks of cardiac rehabilitation intervention. However, the results of the current study showed significantly lower anxiety and depression scores compared with Pourafkari's study.32

The home-based and outpatient-based groups in the current study showed significant increases in physical and mental status after 8 weeks of cardiac rehabilitation intervention, possibly as a result of the positive relationship between aerobic exercise and physical and mental health.33 A number of investigators have investigated the positive effect of exercise on cognitive performance and psychological well-being. Studies indicate exercise as a potential therapy for depression and anxiety34 and as a means of upgrading quality of life through enhanced self-esteem,35 improving mood state, and reducing anxiety and depression. As such, exercise has been found to have a positive impact on psychological well-being and mental health.

Conclusion

The results of the current study corroborate the benefits of home-based cardiac rehabilitation and demonstrate that home-based cardiac rehabilitation can be as effective as outpatient-based cardiac rehabilitation post–coronary artery bypass graft surgery in the KSA. These findings are comparable with those of previous studies. However, the current study was the first to be conducted in the KSA, a different culture and demographic region. A home-based cardiac rehabilitation intervention could be delivered to the Saudi population, especially to patients with CHD and patients post–coronary artery bypass graft surgery living in rural areas. The home-based cardiac rehabilitation program can potentially improve physical fitness, which is a strong positive prognostic indicator of those patients, improving their quality of life and potentially reducing morbidity and mortality.

What’s New and Important

  • The results of this study suggest that both home-based and outpatient-based cardiac rehabilitation can provide patients who have recently had coronary artery bypass graft surgery with positive benefits in exercise capacity and psychosocial outcomes
  • To our knowledge this is the first randomized controlled trial that compares outpatient-based cardiac rehabilitation, home-based cardiac rehabilitation and standard care (no cardiac rehabilitation) conducted in the Saudi population after coronary artery bypass graft surgery.
  • This is one of the first studies that added a 4-week follow-up after the end of intervention period.

REFERENCES

1. World Health Organization (WHO). Mortality Database. Geneva, Switzerland: World Health Organization, Department of Health Statistics and Information Systems; 2015. http://www.who.int/healthinfo/mortality_data/en/.
2. Mendis S, Puska P, Norrving B. Global Atlas on Cardiovascular Disease Prevention and Control. Geneva, Switzerland: World Health Organization; 2011.
3. Mabry R-M, Reeves M-M, Eakin E-G, Owen N. Gender differences in prevalence of the metabolic syndrome in gulf cooperation council countries: a systematic review. Diabet Med. 2010;27(5):593–597.
4. Ponikowski P, Voors AA, Anker SD, et al; Authors/Task Force Members; Document Reviewers. 2016 ESC guidelines for the diagnosis and treatment of acute and chronic heart failure: the task force for the diagnosis and treatment of acute and chronic heart failure of the European Society of Cardiology (ESC). Developed with the special contribution of the Heart Failure Association (HFA) of the ESC. Eur J Heart Fail. 2016;18(8):891–975.
5. Salavati M, Falahinia G, Vardanjani AE, Rafiei H, Moosavi S, Torkamani M. Comparison between effects of home based cardiac rehabilitation programs versus usual care on the patients’ health related quality of life after coronary artery bypass graft. Global J Health Sci. 2016;8(4):196.
6. Manhas P, Palekar TJ, Padmashree DY, Patil Vidyapeeth DY. Effect of CR versus home exercises after coronary artery bypass grafting (CABG) on hemodynamics. Int J Curr Res Rev. 2013;5(15):95.
7. Moholdt T, Vold MB, Grimsmo J, Slørdahl SA, Wisløff U. Home-based aerobic interval training improves peak oxygen uptake equal to residential cardiac rehabilitation: a randomized, controlled trial. PloS One. 2012;7(7):41199.
8. Mutwalli HA, Fallows SJ, Arnous AA, Zamzami MS. Randomized controlled evaluation shows the effectiveness of a home-based cardiac rehabilitation program. Saudi Med J. 2012;33(2):152–159.
9. Hung C, Huang H, Chen H, Lin HC, Hao-LUN L. The effects of short-term cardiac rehabilitation on post-CABG patients' fitness. International Conference on Life Science and Engineering. 2012;45(15):125–129.
10. Wu TY, Yeh HI, Chan P, Chiou YF, Tsai JC. The effects of simple eight-week regular exercise on cardiovascular disease risk factors in middle-aged women at risk in Taiwan. ACTA Cardiol Sin. 2007;3(3):169–176.
11. Eagle KA, Guyton RA, Davidoff R, et al. ACC/AHA guidelines for coronary artery bypass graft surgery: executive summary and recommendations: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Committee to Revise the 1991 Guidelines for Coronary Artery Bypass Graft Surgery). Circulation. 1999;100(13):1464–1480.
12. American College of Sports Medicine (ACSM). A Comprehensive Review. Philadelphia, PA: Walter Kluwer/Lippincott Williams & Wilkins; 2012.
13. American Association of Cardiovascular and Pulmonary Rehabilitation. Guidelines for Cardiac Rehabilitation and Secondary Prevention Program. 5th ed. Champaign, IL: Human Kinetics; 2013.
14. Singh SJ, Jones PW, Evans R, Morgan MD. Minimum clinically important improvement for the incremental shuttle walking test. Thorax. 2008;63(9):775–777.
15. Faul F, Erdfelder E, Lang A-G, Buchner A. G*power 3: a flexible statistical power analysis program for the social, behavioral, and biomedical sciences. Behav Res Methods. 2007;39:175–191.
16. Houchen-wolloff L, Boyce S, Singh S. The minimum clinically important improvement in the incremental shuttle walk test following cardiac rehabilitation. Eur J Prev Cardiol. 2015;22(8):972–978.
17. Portney L-G, Watkins M-P. Foundations of Clinical Research: Application to Practice. 3rd ed. Stamford, CT: Appleton and Lange; 2015.
18. American College of Sports Medicine (ACSM). Guidelines for Exercise Testing and Prescription. 8th ed. Philadelphia, PA: Lippincott Williams & Wilkins; 2010.
19. Singh S-J, Morgan M-D, Scott S, Walters D, Hardman A-E. Development of a shuttle walking test of disability in participants with chronic airways obstruction. Thorax. 1992;47(12):1019–1024.
20. American College of Sports Medicine (ACSM). Guidelines for Exercise Testing and Prescription. Baltimore, MD: Lippincott Williams & Wilkins; 2005.
21. Ainsworth B-E, Haskell W-L, Herrmann S-D, et al. 2011 compendium of physical activities: a second update of codes and MET values. Med Sci Sports Exerc. 2011;43(8):1575–1581.
22. Terkawi AS, Tsang S, Alkahtani GJ, et al. Development and validation of Arabic version of the Hospital Anxiety and Depression Scale. Saudi J Anaesth. 2017;11(suppl 1):S11–S18.
23. Sheikh KA, Yagoub U, Elsatouhy M, Al Sanosi R, Mohamud SA. Reliability and validity of the Arabic version of the SF-36 Health Survey Questionnaire in population of Khat chewers—Jazan region—-Kingdom of Saudi Arabia. Appl Res Qual Life. 2015;10(1):1–13.
24. Zigmond A-S, Snaith R-P. The Hospital Anxiety and Depression Scale. Acta Psychiatr Scand. 1983;67(6):361–370.
25. Mchorney CA, Haley SM, Ware JE Jr. Evaluation of the MOS SF-36 Physical Functioning Scale (PF-10), II: comparison of relative precision using Likert and Rasch scoring methods. J Clin Epidemiol. 1997;50(4):451–461.
26. Mchorney CA, Ware JE Jr, Lu JR, Sherbourne CD. The MOS 36-item Short-Form Health Survey (SF-36), III: tests of data quality, scaling assumptions, and reliability across diverse patient groups. Med Care. 1994;32(1):40–66.
27. Stordal E, Bjartveit Krüger M, Dahl NH, Krüger Ø, Mykletun A, Dahl AA. Depression in relation to age and gender in the general population: the Nord-Trøndelag Health Study (HUNT). Acta Psychiatr Scand. 2001;104(3):210–216.
28. Physiotools—the smart way to create, home exercise programs for physical therapy, rehabilitation and fitness, 2012. https://www.physiotools.com. Accessed June 10, 2019.
29. Thow M.K. Exercise leadership in cardiac rehabilitation: an evidence based approach. 2006; West Sussex, England: Whurr Publishers Limited (a subsidiary of John Wiley & Sons Ltd).
30. Slade SC, Dionne CE, Underwood M, Buchbinder R. Consensus on Exercise Reporting Template (CERT): explanation and elaboration statement. Br J Sports Med. 2016;50(23):1428–1437.
31. Zhang X, Bartol KM. Linking empowering leadership and employee creativity: the influence of psychological empowerment, intrinsic motivation, and creative process engagement. Acad Manage J. 2010;53(1):107–128.
32. Pourafkari L, Ghaffari S, Tajlil A, Shahamfar J, Hedayati S, Nader ND. The impact of CR program on anxiety and depression levels after coronary artery bypass graft surgery. Cor Vasa. 2016;58(4):384–390.
33. Oertel-knöchel V, Mehler P, Thiel C, et al. Effects of aerobic exercise on cognitive performance and individual psychopathology in depressive and schizophrenia patients. Eur Arch Psychiatry Clin Neurosci. 2014;264(7):589–604.
34. Ware J-E. Measuring patients' views: the optimum outcome measure. Br Med J. 1993;306(6890):1429–1430.
35. Borg G. Borg’s Perceived Exertion and Pain Scales. Champaign, IL: Human Kinetics; 1998.
Keywords:

anxiety CABG; cardiac rehabilitation; depression; exercise capacity; home-based; outpatient-based

Copyright © 2020 Wolters Kluwer Health, Inc. All rights reserved.