INJNS (36)(1) (2023) 59-70

Iraqi National Journal of Nursing Specialties

Journal homepage: http s: inj n s.u ob ag hd ad. ed u. iq / in dex .p h p / I N.J.N.S

Effectiveness of Cardiac Rehabilitation Instructional Program on Knowledge and

Health-related Quality of Life for Patients Undergone Coronary Artery Bypass
Graft Surgery
Safad R. Isam*, MScN Hakima Sh. Hassan**, PhD
* University of Baghdad, College of Nursing, Baghdad, Iraq
** University of Baghdad, College of Nursing, Baghdad, Iraq

ARTICLE INFO ABSTRACT

Article history: Objective(s): Determination of effectiveness of cardiac rehabilitation

instructional program on knowledge and health-related quality of life
Received 17 April 2023 for patients undergone Coronary Artery Bypass Graft Surgery and to
Accepted 29 May 2023 find out the relationship between knowledge and health-related quality
of life of patients and their socio-demographic and clinical
characteristics.
Keywords: Methodology: A pre-experimental design (one group, pretest- posttest)
Effectiveness, was carried out from 8th August, 2022 to 10th January, 2023. A non-
Cardiac probability purposive sample of (50) patients undergone coronary artery
Rehabilitation, bypass graft surgery at Iraqi center for heart diseases. The questionnaire
CABG Surgery, and the program contents’ validity was determined by a panel of (18)
HRQoL
experts to evaluate their clarity, relevance, and appropriateness for the
accomplishment of the study.
The reliability of questionnaire was assessed using Cronbach alpha
reliability to estimate its internal consistency. Correlation coefficient of
(0.867) was determined which is acceptable. Patients were asked to fill
the three questionnaires before applying the instructional program (pre-
test), then the program has been presented and discussed through (4)
sessions. After one month, patients were asked to refill the forms (post-
test) to determine the effectiveness of the CR program. Descriptive and
inferential data were analyzed by using: frequency, percentage, mean of
score, standard deviation and paired t test.
Results: The patient’s knowledge about cardiac rehabilitation and
health-related quality of life before applying the program were poor in
most items, while their knowledge increased after applying the program.
Conclusions: The study confirmed the effectiveness of cardiac
rehabilitation instructional program on patients’ knowledge and health-
related quality of life and there was significant positive relationship
between HRQoL and patient’s sociodemographic and clinical
characteristics.
Recommendations: The study recommends the application of current
CRP within Iraqi cardiac hospitals and centers and the need for further
studies on more representative sample.
© 2023 College of Nursing. Published by University of Baghdad

∗ Corresponding author at: University of Baghdad, College of Nursing, Bab Al-

Mua’adham Square, Baghdad, Iraq; E-mail address:
[email protected] (SR Isam). ORCID: https://orcid.org/0000-
0001-7864-1236. DOI: https://doi.org/10.58897/injns.v36i1.809.
©2023 College of Nursing. Published by University of Baghdad.
 Issam S. & Hassan. INJNS (36)(1) 58-70

‫فاعلية برنامج تأهيل قلبي إرشادي على معارف وجودة الحياة المتعلقة بالصحة‬
‫للمرضى الخاضعين لعملية زرع مجازة الشريان التاجي‬
‫المستخلص‬

‫ تحديد فاعلية برنامج التأهيل القلبي اإلرشادي على معارف وجودة الحياة المتعلقة بالصحة للمرضى الخاضعين لعملية زرع مجازة‬:‫األهداف‬
.‫الشريان التاجي ومعرفة العالقة بين معارف وجودة الحياة المتعلقة بالصحة للمرضى وخصائصهم االجتماعية والديموغرافية والسريرية‬
‫ تم اختيار‬.2023 ‫ كانون الثاني‬10 ‫ إلى‬2022 ‫ آب‬8 ‫ اختبار قبلي وبعدي) في الفترة من‬،‫ نـُفذ تصميم قبل التجريبي (مجموعة واحدة‬:‫منهجية البحث‬
‫ تم تحديد‬.‫) مريضا خضعوا لعملية زرع مجازة الشريان التاجي في المركز العراقي ألمراض القلب‬50( ‫عينة غير احتمالية (غرضية) تتكون من‬
‫ تم تقييم موثوقية‬.‫ ) خبير لتقييم مدى وضوحها ومالئمتها وعالقتها إلتمام الدراسة‬18( ‫صالحية االستبانة ومحتويات البرنامج من قبل مجموعة من‬
‫ طُلب من المرضى ملئ االستمارات‬.‫) وهو مقبول‬0.867( ‫ تم تحديد معامل االرتباط‬.‫االستبانة باستخدام معامل كرونباخ الفا لتقدير تناسقها الداخلي‬
‫ طُلب من المرضى‬،‫ بعد شهر واحد‬.‫) جلسات‬4( ‫ ثم تم تطبيق البرنامج ومناقشته من خالل‬،)‫الثالثة قبل تطبيق البرنامج التعليمي (االختبار القبلي‬
،‫ التكرار‬:‫ تم تحليل البيانات الوصفية واالستنتاجية باستخدام‬.‫إعادة ملئ االستمارات (االختبار البعدي) لتحديد مدى فاعلية برنامج التاهيل القلبي‬
.‫ المزدوج‬t ‫ االنحراف المعياري واختبار‬،‫ متوسط الدرجة‬، ‫النسبة المئوية‬
‫ بينما زادت معرفتهم‬،‫ كانت معارف المرضى بإلتأهيل القلبي وجودة الحياة المتعلقة بالصحة قبل تطبيق البرنامج ضعيفة في معظم البنود‬:‫النتائج‬
.‫بعد تطبيق البرنامج‬
‫ أكدت الدراسة فاعلية البرنامج االرشادي للتأهيل القلبي على معارف المرضى وجودة الحياة المتعلقة بالصحة وكانت هناك عالقة‬:‫االستنتاجات‬
.‫ايجابية كبيرة بين جودة الحياة المتعلقة والخصائص االجتماعية والديموغرافية والسريرية للمريض‬
‫ أوصت الدراسة بتطبيق برنامج التأهيل القلبي الحالي داخل مستشفيات ومراكز القلب العراقية والحاجة الى المزيد من الدراسات على‬:‫التوصيات‬
.ً‫عينة أكثر تمثيال‬
.‫ جودة الحياة المتعلقة بالصحة‬،‫ عملية زرع مجازة الشريان التاجي‬، ‫ تأهيل القلب‬،‫ فاعلية‬:‫الكلمات المفتاحية‬

Introduction
Coronary artery disease (CAD) overcome the declining efficiency of recent
continues to be the futuristic single reason studies for managed CAD cases. (9).
for death globe wide until the year 2030 (1). Nurses play a key role in improving
Cardiovascular disease is the leading cause patients’ life by increasing their awareness
of death in about 63% of chronic disease about disease risk factors through
deaths worldwide (2) (3). self‑ care educational programs (3).
Coronary artery bypass graft surgery Cardiac rehabilitation program (CRP) is
(CABGs) is a global scope surgery that a multi-disciplinary approach including
deemed as the most common cardiac supervised exercise training, patient
surgery performed today (4). counseling, education and nutritional
Studies showed that post-operative guidance that may also enhance patient’s
complications increased with physical quality of life (QoL) (10). In addition,
inactivity and therefore reduces patient’s cardiac rehabilitation is an effective
quality of life. Furthermore, continuous strategy in the care of patients who had
and appropriate comprehensive nursing CAD and in lowering the cardio vascular
care will continue to be important for mortality rate (11).
enhancing patient’s recovery (5). Constructing a program for cardiac
In addition, the non-modifiable risk rehabilitation among patients with open
factors for CAD include; smoking, heart surgery is very beneficial. Also a
hypertension, hypercholesterolemia obesity follow-up monitoring education is highly
and diabetes. While modifiable risk factors advised (12).
include lack of exercise, an unhealthy diet The CR programs strive to improve
and stress (6). These risk factors considered health-related quality of life (HRQL),
as consequent contributors in the reduce complications, relief symptoms, as
development of CAD (7). Thus, risk factor well as prolonging life. Besides prolonging
management is a crucial first step in life, the objectives of CR include the
dealing with cardiovascular event (8). improvement of physical functioning and
Low mortality rates rise the need for general wellbeing (9).
homogenous sample in future studies to

60
 Issam S. & Hassan. INJNS (36)(1) 58-70

A recently published meta-analysis (2) Both male and females, undergone

results showed that cardiac rehabilitation CABGs with no major pulmonary
programs improved health-related quality complications.
of life while only two trails exceeded that The patients have signed a consent
of the controls (13). form to acknowledge their voluntary
The built-in training exercises participation with no coercion and the
conducted within CRP links patient’s confidence that their data will be used for
performance with their HRQoL (14). For research purposes only.
those patients undergone CABGs, it is Direct interview was used in data
highly recommended to engage in CRP in collection from the study sample through
order to increase their functional exercise the use of a questionnaire composed of
through daily walking and aerobic three parts:
exercises (15). Part I: Patients’ socio-demographic
Ordinarily, a regular physical activity and clinical characteristics which included
program should be implemented to 11 items; age, gender, marital status,
improve patient’s physical fitness and educational level, occupation, smoking,
enhance HRQoL. Targeting a minimum of body mass index, disease diagnosis,
thirty minutes of moderate physical blocked coronary arteries, ejection fraction
exercise daily should be the aim of each and NYHA classification).
participant (16). Part II: Evaluation of Patient’s
In Iraq, approximately 2200 patients knowledge about cardiac rehabilitation
undergone CABGs in 2021. About 1800 which includes 20 multi-choice questions
patient survived the complications of with 1 correct choice and 3 incorrect ones.
surgery. However, there are no reports of These questions adopted from relevant CRP
cardiac rehabilitation referrals as a result of literatures.
the absence of specialized cardiac Part III: Evaluation of patients’
rehabilitation centers (17). Health-related quality of life (HRQoL)
The current study was conducted to which include 5 domains adopted from
reinforce the importance of the CR Euro-QoL (EQ-5D). This tool scored using
program in decreasing surgery three levels Likert scale; (3) for no
complications and improving patient’s problems, (2) for some problems and (1) for
HRQoL, thus it aims to determine the major problems.
effectiveness of cardiac rehabilitation The questionnaire and the program
instructional program on health-related contents’ validity was determined by a
quality oflife. panel of (18) experts from University of
Baghdad/ College of Nursing, Iraqi Center
Methodology for Heart Diseases and Ibn Al-Bittar
A pre-experimental design (one group, Specialized Center for Cardiac Surgeries.
pretest- posttest) carried out in Iraqi Center These experts were with at least ten years
for Heart Diseases (ICHD) at Medical City of expertise in the research area, they
Directorate. evaluated their clarity, relevance, and
The study was conducted from 8th appropriateness for the accomplishment of
August, 2022 to 10th January, 2023 at the study.
ICHD. A non-probability (purposive) The reliability of the questionnaire
sample of (50) patients undergone CABG was assessed using Cronbach alpha
surgery were enrolled in cardiac reliability to estimate its internal
rehabilitation program. consistency. Correlation coefficient of
Patients were selected according to the (0.867) was determined which is
following criteria; acceptable.
(1) Adult patients. All participants were asked to fill the
three questionnaires before applying the

61
 Issam S. & Hassan. INJNS (36)(1) 58-70

instructional program (pre-test), then the asked to refill the forms (post-test) to
program has been presented and discussed determine the effectiveness of the CR
through (4) sessions. First session was program.
about CAD; second session was about The statistical software (SPSS) ver.
explaining CABG surgery and patient care 23 was used for data analysis of the study,
(pre, intra, and postoperative); third session using; frequency, percentage, mean of
was about CR program and the fourth score, standard deviation, and paired t test.
session was about the training exercises. A p value ≤ 0.05 was counted as
After one month, the participants were statistically significant

Results
Table (1): Distribution of the Patients According to Their Sociodemographic and
Clinical Characteristics
Variables Characteristics F %
38- 47 years 4 8
48- 57 years 19 38
58- 67 years 16 32
Age (years)
≥ 68 years 11 22
Total 50 100
M.S ± SD (4.68 ± 0.913)
Male 33 66
Female 17 34
Gender
Total 50 100
M.S ± SD (1.34 ± 0.479)
Married 35 70
Divorced 2 4
Marital status Widowed 13 26
Total 50 100
M.S ± SD (2.56 ± 0.884)
Middle school 12 24
Secondary school 20 40
Educational Level Institute\ college 18 36
Total 50 100
M.S ± SD (5.12 ± 0.773)
Employee 19 38
Free job 13 26
Retired 8 16
Occupation
Housewife 10 20
Total 50 100
M.S ± SD (3.18 ± 1.155)
Non Smoker 19 38
Smoker 5 10
Smoking Ex- Smoker 26 52
Total 50 100
M.S ± SD (2.14 ± 0.948)
Normal
20 40
(18.5- 24.9 kg\m2)
Body Mass Index (BMI)
Overweight
27 54
(25- 29.9 kg\m2)

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 Issam S. & Hassan. INJNS (36)(1) 58-70

Obese Class l
3 6
(30- 34.9 kg\m2)
Total 50 100
M.S ± SD (2.66 ± 0.593)
1- 5 years 30 60
6- 10 years 18 36
Diagnosis 11- 15 years 2 4
Total 50 100
M.S ± SD (2.44 ± 0.577)
2 arteries 14 28
3 arteries 34 68
No. of Blocked Coronary Arteries > 3 arteries 2 4
Total 50 100
M.S ± SD (2.76 ± 0.517)
Reduced EF (≤ 40%) 18 36
Borderline EF (41-
30 60
49%)
Ejection Fraction (EF)
Normal EF (50- 70%) 2 4
Total 50 100
M.S ± SD (1.68 ± 0.551)
Class II 29 58
Class III 21 42
NYHA Classification
Total 50 100
M.S ± SD (2.42 ± 0.499)
2
F= Frequency, %= Percent, M.S.= Mean of score, SD= Standard deviation, Kg\M = Kilogram\Square
meter, NYHA=New York Heart Association
The results of table (1) showed that the highest percentage of the patients were within
the age group (48- 57) years (38%), the majority of patients were male (66%), most of them
were married (70%), with an educational level of secondary school graduate (40%). Most of
patients were employed (38%). Half of patients were ex-smokers (52%). Most of them were
overweight (54%). Regarding patient’s clinical characteristics; most of them were diagnosed
with CAD before (1- 5) years (60%). Three blocked arteries were blocked in the majority of
patients (68%) prior to CABGs with a borderline ejection fraction (41- 49%) in (60%) of
patients. In relation to NYHA classification; most of the patients were staged in class II
(58%).

63
 Issam S. & Hassan. INJNS (36)(1) 58-70

Figure (1): Distribution of Patients According to Chronic Diseases

Table (2): Evaluation of Patients’ Knowledge about Cardiac Rehabilitation at the

Pre-test and Post-test Periods by Their Means of Scores
Test Pre-Test Post-Test
No. Items
Responses F % M. S. Ass. F % M.S. Ass.
Correct A. 9 18 47 94
1 Normal adult heart rate 1.18 P 1.94 G
Incorrect A. 41 82 3 6
Correct A. 7 14 1.14 P 41 82 1.82 G
2 Function of coronary arteries
Incorrect A. 43 86 9 18
Correct A. 4 8 1.08 P 35 70 1.70 G
3 The main cause of CAD
Incorrect A. 46 92 15 30
Modifiable risk factors of Correct A. 6 12 1.12 P 41 82 1.82 G
4
CAD Incorrect A. 44 88 9 18
Pre-operative preparing Correct A. 5 10 1.10 P 38 76 1.76 G
5
patient for CABGs Incorrect A. 45 90 12 24
Best direction for patient Correct A. 19 38 1.38 F 37 74 1.74 G
6
assurance before CABGs Incorrect A. 31 62 13 26
Medications stopped one Correct A. 14 28 1.28 P 43 86 1.86 G
7
week before CABGs Incorrect A. 36 72 7 14
The perfusion machine used Correct A. 3 6 1.06 P 32 64 1.64 F
8
during CABGs Incorrect A. 47 94 18 36
The number of grafts Correct A. 9 18 1.18 P 32 64 1.64 F
9
required for CABGs Incorrect A. 41 82 18 36
Correct A. 46 92 1.92 G 48 96 1.96 G
10 Anesthesia used in CABGs
Incorrect A. 4 8 2 4
Correct A. 18 36 1.36 F 47 94 1.94 G
11 Goals of patient care in ICU
Incorrect A. 32 64 3 6
Encourage supporting chest Correct A. 17 34 1.34 F 48 96 1.96 G
12
during coughing Incorrect A. 33 66 2 4
Training deep breathing Correct A. 13 26 1.26 P 47 94 1.94 G
13
techniques in ICU Incorrect A. 37 74 3 6
Discussing discharge plan in Correct A. 4 8 1.08 P 33 66 1.66 F
14
phase I of CRP Incorrect A. 46 92 17 34
Main focus of phase II of Correct A. 15 30 1.30 P 32 64 1.64 F
15
CRP Incorrect A. 35 70 18 36
Importance of eating healthy Correct A. 7 14 1.14 P 41 82 1.82 G
16
diet for heart Incorrect A. 43 86 9 18
Goals of training exercises Correct A. 11 22 1.22 P 42 84 1.84 G
17
after CABGs Incorrect A. 39 78 8 16
Preparations before training Correct A. 19 38 1.38 F 42 84 1.84 G
18
exercises Incorrect A. 31 62 8 16
Cautions during training Correct A. 16 32 1.32 P 37 74 1.74 G
19
exercises Incorrect A. 34 68 13 26
Correct A. 6 12 1.12 P 40 80 1.80 G
20 Wound healing precautions
Incorrect A. 44 88 10 20

64
 Issam S. & Hassan. INJNS (36)(1) 58-70

CAD= Coronary artery disease, CABGs= Coronary artery bypass graft surgery, ICU= Intensive care unit,
CRP= Cardiac rehabilitation program, F= Frequency, %= Percentage, M.S.= Mean of score
Assess. =Level of assessment, 1-1.33- =Poor (P), 1.34-1.66= Fair (f), 1.67-2= Good (G)
Table (2) showed that patient’s knowledge about cardiac rehabilitation before applying
the program were poor in all items except in items concerning with (anesthesia, goal of ICU
care, patient’s assurance patient’s encouragement and preparations before training exercises)
which were fair. The patient’s knowledge after applying cardiac rehabilitation program were
good in all items except in items concerning with (heart-lung machine, used grafts, discussion
of discharge plan and the main focus of phase II) which were fair.
Table (3): Overall Evaluation of Patient’s Knowledge about Cardiac Rehabilitation
Program at Pre-Test and Post-Test Periods
Pre-test Post-test
Variable
Level F % Level F %
Poor 44 88 Poor 0 0
Knowledge about Fair 6 12 Fair 4 8
Cardiac Rehabilitation Good 0 0 Good 46 92
Program Total 50 100 Total 50 100
M.S±SD (1.12±0.328) M.S±SD (2.92±0.274)
F= Frequency, %= Percent, M.S= Mean of score, SD=standard deviation,
Assess. =Level of assessment, 1-1.33- =Poor (P), 1.34-1.66= Fair (f), 1.67-2= Good (G)
Table (3) showed that the overall evaluation of patient’s knowledge about cardiac
rehabilitation were poor (88%) before applying the program while their knowledge became
good (92%) after applying the program.

Table (4): Evaluation of Health-Related Quality of Life for Patients at Pre-Test and
Post-test Periods
Pre-test Post-test
Variable
F % M.S. SD F % M.S. SD
1. Mobility
- No problem 2 4 2.16 36 72 1.28
0.468 0.454
- Some Problems 38 76 MS 14 28 LS
- Extreme Problems 10 20 0 0
2. Self-Care
- No problem 5 10 2.14 9 18 1.82
0.572 0.388
- Some Problems 33 66 MS 41 82 MS
- Extreme Problems 12 24 0 0
3. Usual Activities
- No problem 14 28 2.22 3 6 2.02
0.545 0.319
- Some Problems 33 66 MS 45 90 MS
- Extreme Problems 3 6 2 4
4. Pain/ Discomfort
- No problem 0 0 2.80 28 56 1.46
0.404 0.542
- Some Problems 10 20 HS 21 42 LS
- Extreme Problems 40 80 1 2
5. Anxiety/ Depression
- No problem 0 0 2.68 33 66 1.34
0.471 0.479
- Some Problems 16 32 HS 17 34 LS
- Extreme Problems 34 68 0 0
No. = Number, M.S.= Mean of score, SD= Standard deviation, LS = Low significance, MS = Moderate
significance, HS= High significance. Level of significance (LS = 1- 1.66, MS = 1.67- 2.32, HS= 2.33- 3).

65
 Issam S. & Hassan. INJNS (36)(1) 58-70

Table (4) showed that most of the study sample at pre-test period were having some
problems in mobility (76%), usual activities (66%) and self-care (66%) while most of them
were having extreme problems in pain\ discomfort (80%) and anxiety\ depression (68%).
Compared to pre-test results, the post-test results showed that most of patients were having no
problems in items concerning with mobility (72%), pain\ discomfort (56%) and anxiety\
depression (66%). While most of them had some problems in self-care (82%) and usual
activities (90%).
Table (5): Comparison Significance in Patient’s Knowledge about Cardiac
Rehabilitation
and Their Health-related Quality of Life
Paired t Test
Variables M.S. SD t test
df Sig.
value
Cardiac Rehabilitation Program 2.92 0.274 0.000
15.903 49
Health-related Quality of Life 1.60 0.494 HS
M.S.= Mean of score, SD= Standard deviation, df = Degree of freedom, Sig= significance, HS= High
significance.
Table (5) showed that there were high significant statistical differences at p 0.05
between patient’s knowledge about CRP and their health-related quality of life.
Table (6): Association between Patient’s Health-related Quality of Life and Their
Sociodemographic and Clinical Characteristics.
Paired t Test
Socio-demographic and
M.S. SD t test
Clinical Characteristics df Sig.
value
0.000
1. Age 4.68 0.913 21.207 49
(HS)
0.018
2. Gender 1.34 0.479 2.449 49
(HS)
0.000
3. Educational Level 5.12 0,773 28.847 49
(HS)
0.000
4. Occupation 3.18 1.155 9.080 49
(HS)
0.000
5. Smoking 2.14 0.984 3.764 49
(HS)
0.000
6. BMI 2.66 0.593 8.891 49
(HS)
0.000
7. Diagnosis 2.44 0.577 8.723 49
(HS)
0.000
8. NYHA Classification 2.42 0.499 7.757 49
(HS)
BMI= Body mass index. NYHA= New York Heart Association, SD= Standard deviation,
df= Degree of freedom, Sign.= Significance, HS= High significance

Table (6) showed that there were highly significant statistical differences at p 0.05
between HRQoL and patient’s sociodemographic and clinical characteristics, this means that
there is significant positive relationship between HRQoL and patient’s age, gender,
educational level, occupation, smoking, BMI, Diagnosis and NYHA classification.

66
 Issam S. & Hassan. INJNS (36)(1) 58-70

Discussion studies done locally and worldwide that

The study findings concerning reported that there are no significant
patient’s socio-demographic characteristics differences in baseline characteristics and
revealed that majority of patients were chronic diseases; ischemic heart disease,
males and married, these findings were hypertension, diabetes, and rheumatoid
supported by a study on adult patients arthritis) (21,) (22).
undergoing CABG surgery in which According to the analysis of patient’s
revealed that the majority of study sample knowledge about cardiac rehabilitation
were male patients (18). program, the results revealed that patient’s
Concerning the educational level and knowledge before applying the program
occupation, the results showed that was poor in all items except in (4) items
majority of patients were secondary school concerning with anesthesia, goal of ICU
graduate and only third of them were care, patient’s assurance patient’s
employed, this result agrees with a multi- encouragement and preparations before
site study among cardiac rehabilitation training exercises, which was fair. While
patients in Canada, in which about one- their knowledge after applying the program
third of sample were graduated from high were good in all items except in items
school and were employees (19). concerning with heart-lung machine, used
Most of patient were within age group grafts, discussion of discharge plan and the
(48-57) years, half of them were ex- main focus of phase II which were fair.
smokers and overweight ranging from (25- These results were similar to meta study
29.9 kg/m2) according to BMI discussing the effects of applying CR
classification. These results are similar to programs in patients undergone open heart
another study that discussed the patients' surgery (23).
awareness about CVD, which revealed that Patient’s knowledge about CR
most of sample were ex-smokers and program were increasingly enhanced after
overweight (7). applying the program. These findings have
Majority of patients diagnosed with been verified by an Indian scientific review
CAD since 1-5 years, two-thirds of them through structured literature search in
were having 3-blocked coronary artery and discreet scientific databases for studies
tested with an ejection fraction (EF) at focusing on CR programs and their impact
borderline (41- 49%). Similar studies on physical activity and patient’s quality of
reflected that such results where most life following open heart surgery (24).
patients with borderline EF are Classified Most of patients were experiencing
into class II according to NYHA some problems in pre-tetb period while the
classification (20) (21). post-test results showed that there were
Regarding patients’ past medical less problems. These results supported by a
history; the results showed that all patients study tracing participation and completion
have at least two chronic diseases. All of CR programs among Medicare patients
(25) (26)
patients were suffering from ischemic heart .
disease. Most of the patients were having Furthermore, the comparison between
diabetes and hypertension. While the patient’s knowledge about CR program
majority of them were not suffering from and their HRQoL revealed that there were
rheumatoid arthritis and respiratory high significant statistical differences at p
infections. These results agree with several 0.05. This means that the applied CR
67
 Issam S. & Hassan. INJNS (36)(1) 58-70

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