Although mortality rates have decreased in developed countries, cardiovascular disease remains the leading cause of death. Hence, the need for further research to understand the causes, risk factors, and predictors of heart disease.1

Cardiac rehabilitation programs aim to reduce the physical and psychological consequences that a coronary event causes, to control symptoms, to promote psychosocial well-being, and to facilitate the return-to-work life by reducing the possibility of a new event.2 Cardiac rehabilitation is not only associated with a decrease in morbimortality and disability, but also with an increase in quality of life and a reduction in the number of hospitalizations, so this is a cost-effective therapeutic measure.3

The aim of the present work is to measure the impact of a cardiac rehabilitation program on the quality of life of patients with heart disease in the short and long term, assessing adherence to the program over four time points. In this way, this work contributes to determine the measurement of quality of life as an indicator of rehabilitation efficacy.

In cardiac rehabilitation programs health-related quality of life (HRQoL) is considered a subjective assessment. HRQoL relates to how the disease affects the patients’ life and is very useful for planning future care, as it is predictive of response to treatment and also facilitates decision-making.4 Nevertheless, a series of symptoms that influence quality of life and accompany people who have recently suffered a coronary event should be noted. Patients usually refer decreased endurance when walking or climbing stairs, increased dyspnea, or feeling short of breath during physical activity and fatigue. The physical exertion and emotional stress to which they are subjected is sometimes accompanied by chest pain. Any type of physical exercise, the resumption of sexual relations or the return-to-work are cause for anxiety. In many cases, symptoms indicative of depression appear, such as emotional lability, poor quality sleep, and a lack of interest in previously pleasurable activities.5

Although current recommended therapies for coronary artery disease (pharmacological or revascularization by surgery or percutaneous coronary intervention) are very effective in reducing angina symptoms and improving prognosis, patients continue to live with chronic heart disease with potential complications, ranging from advanced heart failure to adverse cardiac events and even death.6 Therefore, these patients are still associated with high burdens of morbidity, mortality, readmission rates, and increased cost of care. It becomes essential to develop effective interventions to help patients with coronary artery disease to adequately manage their chronic disease.7 In line with the above literature, the hypothesis 1 is formulated as follows: scores in the quality-of-life domains will increase after participation in the cardiac rehabilitation program, denoting better quality of life.

The Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) guidelines were followed and data are collected and stored in a pseudonymized manner. The study was conducted in compliance with the Declaration of Helsinki, the law 14/2007 on biomedical research and other applicable regulations. The handling of personal data complied with the provisions of Regulation (EU) 2016/6798 on the protection of individuals with regard to the processing of personal data and on the free movement of such data and repealing Directive 95/46/EC.

The HRQoL domains with the highest scores were physical function, social functioning, emotional role, and mental health (Table 2). Body pain, general health, and vitality showed lower scores. Differences in physical role (linked to problems with work or other daily activities due to physical health) across the four time points may be related to return-to-work and/or adaptation to the job.

To assess adherence to the rehabilitation program, mean scores were compared between the last data collection and the first visit (Table 3). One year after the end of the program (T4), patients maintained higher scores in all domains compared to the start of cardiac rehabilitation (T1), except for the emotional role dimension (differences were not significant, P=.329).

Regarding the transitional domain, scores were increased after the rehabilitation program (Fig. 1). At T1, 37% of the participants considered their health to be worse than it was one year ago. At T2, 31.2% perceived their health to be somewhat better. At T3, 44% of the patients perceived that their health was already much better, and at T4, 30.8% still maintained the perception of their health status as somewhat better.

Fig. 1.

Score in the transition domain: time evolution. Values expressed in absolute frequency.

Next, differences were analyzed according to educational level (Table 4). A total of 46.4% of the participants completed primary education, 35.9% finished secondary education, and only 17.7% held a university degree. At T1, significant differences were found in the domains of physical function, physical role, and general health, so that university patients exhibited the highest scores. However, in the domains of social functioning, emotional role, and mental health there seems to be less correlation between the educational level and a better perception of health. At T4, significant differences were only found in the physical function domain (P=.003), so that university participants presented again higher scores. Participants, regardless of their level of education, perceived a significant improvement at T4 with respect to T1 in all domains. These data on educational level are relevant when assessing adherence to rehabilitation programs. As the literature suggests, the lower the educational level, the greater the difficulties in communicating with health professionals. Furthermore, a low level of schooling is associated with disadvantages due to lower income and lack of knowledge of the cardiovascular risk factors that affect their health.14

With respect to participants suffering from anxiety/stress (as reported at T1), results show significant differences in all domains, except in physical function and pain (Table 5). Participants who admit to suffering from anxiety/stress (44.2%) showed a worse perception of health. Anxiety and stress have a very significant prevalence in patients with heart disease.15 Emotional lability, lack of interest in what was previously pleasurable, or poor sleep quality are symptoms indicative of deterioration in quality of life. Sometimes the emotional stress to which they are subjected may be accompanied by chest pain, a factor that causes anxiety when having sexual relations or thinking about the future return-to-work.5 At the end of cardiac rehabilitation, this study reveals an improvement in patients’ perception of their health. Results suggest that the cardiac rehabilitation program is particularly beneficial for those who do acknowledge suffering from anxiety and stress problems.

As for physical activity, only 56.9% of the sample admitted to being active. Participants who admitted to being active at T1 obtained higher scores in all domains (Table 6), being differences more striking regarding mental health and general health. At T4 all participants reported higher scores than at T1, regardless of their activity/inactivity. These data confirms that physical inactivity and sedentary lifestyles are one of the main health problems in our society, and are in line with previous literature showing that physical activity improves health status, regardless of age, sex, race, or ethnicity.16 Physical inactivity is associated with increased cardiac mortality, whereas exercise, even moderate exercise, is associated with a survival benefit.12

In relation to diet, only 24.3% of the participants admit to eating healthy, which translates into the percentage of poor weight control (51.1%) and high blood pressure (51.4%). Those who admitted to following a healthy diet at T1 obtained higher scores compared to those who did not eat well, particularly in social functioning, mental health, and physical function (Table 7). At T4, all participants, regardless of their diet, managed to increase their scores.

Results show the positive relationship that cardiac rehabilitation has on patients’ perception of health and support that cardiac rehabilitation programs reduce the physical and psychological consequences caused by cardiovascular disease, promoting psychosocial well-being, and reducing the chances of a new event.2,17,18 Regarding the transition domain, the perception of health with respect to one year time, this longitudinal study confirms adherence to what was learned in the cardiac rehabilitation programs, with the participants maintaining this better perception of health. It is necessary to highlight the importance of preventive work to avoid coronary disease. Preventive actions performed by nursing professionals promote health and prevent disease by avoiding the need for acute or rehabilitative care.19 Making prevention a priority is one of the pending issues in medicine,20 since interventions focused on promoting health by reducing cardiovascular risk factors are critical in terms of leading a healthy lifestyle, which determines a 92% and 66% lower risk of coronary heart disease and of presenting clinical manifestations of cardiovascular disease risk factors, respectively.21

Present results show that nearly 1 in 4 patients admit to eating healthy. On the other hand, patients adhere to pharmacological treatment in a 98.3%. These data call for the work that still lies ahead. It is more complicated to change lifestyle than to take the prescribed medication. The study also shows the percentage of participants who continue to smoke (40.8%) after suffering a coronary event. The evidence suggests that more than half of the reduction in cardiovascular mortality has been attributed especially to the reduction in blood pressure, cholesterolemia, and smoking, a favorable trend counterbalanced by the increase in obesity and type 2 diabetes.22 These findings highlight once again the need to reinforce in educational talks the importance of not seeing medication as either the only or the best part of treatment. All self-care interventions aimed at empowering patients to improve the control of their health status become essential in order not to put their health and consequently their quality of life at risk as suggested by the literature consulted.18

From a gender perspective, the incidence rate of coronary heart disease is higher in men than in women, and female participation in rehabilitation programs is low. In the study, only 19.9% of the participants were women. Gender roles are related to women as caregiver and dependent on the household. Additionally, insecurity or lack of previous experience with exercise or limited cultural support for leading a physically active lifestyle has been appointed in the literature.23 Another important aspect is feeling accompanied (92.3%). Patients who do not feel alone find more help when considering lifestyle reforms and coping with the disease.24

Another finding of this study is the importance of health check-ups as reinforcement of what has been learned in terms of cardiovascular risk factors. It is very common for patients to find no time for exercise when they start working and their diet is once again improvised, making use of fast food, something that has repercussions on their blood pressure, body weight and analytical data. Results show a decrease in the scores at the 4-month revision (T3) in both the physical and emotional roles, figures that went up again at the next revision (T4). This suggests the relevance of educational reinforcement in terms of control of risk factors and/or medication adjustments. Therefore, the measurement of quality of life has a high relevance since the evolution of improvement in the physical, social, and emotional role increases patients’ adherence to drug therapy, clinical controls, and a healthy lifestyle, including exercise (Fig. 2).25

Fig. 2.

Central illustration. Phases of the cardiac rehabilitation program, control variables, lifestyle interventions, and patient benefits. T, timepoint.

The results of this study show the positive impact of cardiac rehabilitation on patients’ quality of life. In line with previous publications, patients who attend a cardiac rehabilitation program improve their quality of life, decrease the number of complications, and delay the progression of the disease. Positive influence is not limited to the physical condition, but also extends to the mental and social condition.25

Attendance to these programs translates into improvements in self-management of the disease. Our findings reveal participants’ improvement in all the domains analyzed, so we conclude cardiac rehabilitation is a key factor in their recovery, slowing the progression of the disease and decreasing the likelihood of new cardiovascular events. We believe it is important to emphasize the importance of continuing to work on prevention, since the aging and growth of the world's population is increasing the number of deaths from cardiovascular diseases, with low and middle-income countries facing a growing number of people suffering from cardiovascular diseases at younger ages.32

This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.

The study was approved by the regional research ethics committee of Santiago-Lugo (Spain). The Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) guidelines were followed, and data are collected and stored in a pseudonymized manner. The study was conducted in compliance with the Declaration of Helsinki, the law 14/2007 on biomedical research and other applicable regulations. The handling of personal data complied with the provisions of Regulation (EU) 2016/6798 on the protection of individuals with regard to the processing of personal data and on the free movement of such data and repealing Directive 95/46/EC.

This manuscript did not use artificial intelligence for its preparation.

M.J. Ferreira-Díaz participated in conceptualization, coordination of the intervention program at the hospital, data collection, data analysis, manuscript writing, review, and editing of the original manuscript. G. Topa participated in the conceptualization, supervision, and writing of the original manuscript. A. Laguía participated in manuscript writing, review, and editing of the original manuscript. This study has been carried out in the framework of the doctoral thesis of M.J. Ferreira-Díaz, supervised by G. Topa and A. Laguía.

The authors declare that they have no competing interests.