Prehabilitation: The Right Medicine for Older Frail Adults Anticipating Transcatheter Aortic Valve Replacement, Coronary Artery Bypass Graft, and Other Cardiovascular Care

https://doi.org/10.1016/j.cger.2019.07.006Get rights and content

Section snippets

Key points

  • Strategies to improve postoperative outcomes after cardiac procedures are needed because older and frailer patients are being referred for surgery.

  • Prehabilitation improves the outcomes of patients awaiting cardiac surgery, while lowering health care costs through reductions in intensive care unit and hospital length of stay.

  • Further high-quality research examining multimodal interventions in populations, such as those who are older, frail individuals, and women, is needed to provide additional

Complications of frail older adults in cardiac surgery

The pathophysiology surrounding the development of frailty is not fully understood, but one line of inquiry is that the gradual accumulation of cellular or subclinical damage over one’s lifetime gives rise to clinically observable health deficits,15 such as CVD. Frailty has been shown to be associated with increased risk for developing CVD in longitudinal studies,4, 16 and those with known CVD risk have also been shown to be at increased risk for developing frailty.17 The relationship between

Improving recovery from surgery

Cardiac rehabilitation is the accepted standard of care after surgery,31, 32 because evidence demonstrates that engaging in physical activity after cardiac surgery is key to enhancing health for patients postsurgery.10, 33 For example, cardiac rehabilitation serves as a means of promoting physical activity and healthy behaviors, which in turn reduces risk of hospital readmission, cardiac mortality, and all-cause mortality.34, 35, 36 However, only 30% of cardiac patients enroll in cardiac

Completed cardiac prehabilitation trials

The first seminal prehabilitation trial in cardiac patients was conducted by Arthur and colleagues47 in 2000. The preoperative intervention included 249 patients waiting for elective CABG procedure and followed a traditional center-based cardiac rehabilitation model. Patients randomized to the intervention received education on risk factor modification, monthly support calls from a nurse, and two exercise sessions per week for a period of 8 weeks. Hospital length of stay postoperatively was

Ongoing cardiac prehabilitation trials

Table 2 summarizes eight prehabilitation clinical trials currently recruiting participants in cardiac populations found on the ClinicalTrials.gov Web site. Studies include participants from the United States,58, 59, 60, 61 Canada,62, 63, 64 and Spain.65 Patient populations include those awaiting transcatheter aortic valve replacement,58, 60, 64 CABG,62, 65 thoracic aortic repair,59 heart transplant,63, 65 or valve surgery,62 and patients with vascular disease.61 Mainly trials are recruiting

The future of prehabilitation in cardiac surgery

The emerging accumulation of evidence demonstrates that cardiac prehabilitation is the right medicine for patients undergoing cardiac procedures. Additional randomized controlled trials with larger cohorts in a wider variety of cardiac surgical procedure contexts, such as TAVI, are needed to further strengthen this evidence, and the inclusion of specific clinical outcomes, such as associated health care costs and surgical outcomes. These data are needed to inform future health care policy

Summary

The implementation of prehabilitation programs in advance of surgery will become increasingly vital in the ever-growing population of older, frailer cardiac patients. The effects of prehabilitation extend beyond improved patient outcomes and are economically impactful. Moreover, prehabilitation programs build on the strength of existing postoperative cardiac rehabilitation infrastructure through the initiation of similar care earlier in the patient journey. High-quality, creative research

First page preview

First page preview
Click to open first page preview

References (82)

  • P. Green et al.

    The impact of frailty status on survival after transcatheter aortic valve replacement in older adults with severe aortic stenosis: a single-center experience

    JACC Cardiovasc Interv

    (2012)
  • A. Sepehri et al.

    The impact of frailty on outcomes after cardiac surgery: a systematic review

    J Thorac Cardiovasc Surg

    (2014)
  • M. Goldfarb et al.

    Cost of cardiac surgery in frail compared with nonfrail older adults

    Can J Cardiol

    (2017)
  • N.K. Wenger

    Current status of cardiac rehabilitation

    J Am Coll Cardiol

    (2008)
  • C.J. Lavie et al.

    Exercise training and cardiac rehabilitation in primary and secondary prevention of coronary heart disease

    Mayo Clin Proc

    (2009)
  • R.S. Taylor et al.

    Exercise-based rehabilitation for patients with coronary heart disease: systematic review and meta-analysis of randomized controlled trials

    Am J Med

    (2004)
  • W. Dafoe et al.

    Canadian Cardiovascular Society Access to Care Working Group on Cardiac Rehabilitation. Universal access: but when? Treating the right patient at the right time: access to cardiac rehabilitation

    Can J Cardiol

    (2006)
  • S.L. Grace et al.

    Systematizing inpatient referral to cardiac rehabilitation 2010: Canadian Association of Cardiac Rehabilitation and Canadian Cardiovascular Society Joint Position Paper: Endorsed by the Cardiac Care Network of Ontario

    Can J Cardiol

    (2011)
  • R.C. Arora et al.

    “NEW” prehabilitation: a 3-way approach to improve postoperative survival and health-related quality of life in cardiac surgery patients

    Can J Cardiol

    (2018)
  • H.-H. Tung et al.

    Effects of a preoperative individualized exercise program on selected recovery variables for cardiac surgery patients: a pilot study

    J Saudi Heart Assoc

    (2012)
  • D. Santa Mina et al.

    Effect of total-body prehabilitation on postoperative outcomes: a systematic review and meta-analysis

    Physiotherapy

    (2014)
  • D. Snowdon et al.

    Preoperative intervention reduces postoperative pulmonary complications but not length of stay in cardiac surgical patients: a systematic review

    J Physiother

    (2014)
  • V. Vaccarino et al.

    Gender differences in recovery after coronary artery bypass surgery

    J Am Coll Cardiol

    (2003)
  • E. Oosenbrug et al.

    Sex differences in cardiac rehabilitation adherence: a meta-analysis

    Can J Cardiol

    (2016)
  • D.S. Kehler et al.

    The association between bouts of moderate to vigorous physical activity and patterns of sedentary behavior with frailty

    Exp Gerontol

    (2018)
  • D.S. Kehler et al.

    A systematic review of the association between sedentary behaviors with frailty

    Exp Gerontol

    (2018)
  • WHO | World report on ageing and health

  • Executive summary: tracking heart disease and stroke in Canada 2009

  • L.P. Fried et al.

    Untangling the concepts of disability, frailty, and comorbidity: implications for improved targeting and care

    J Gerontol A Biol Sci Med Sci

    (2004)
  • L.P. Fried et al.

    Frailty in older adults: evidence for a phenotype

    J Gerontol A Biol Sci Med Sci

    (2001)
  • D.S. Kehler et al.

    Prevalence of frailty in Canadians 18-79 years old in the Canadian health measures survey

    BMC Geriatr

    (2017)
  • Expert recommendations - ERAS

  • J.M. Torpy et al.

    JAMA patient page. Frailty in older adults

    JAMA

    (2006)
  • J.-A.V. Sawatzky et al.

    Prehabilitation program for elective coronary artery bypass graft surgery patients: a pilot randomized controlled study

    Clin Rehabil

    (2014)
  • R.M. Nery et al.

    Effect of leisure-time physical activity on the prognosis of coronary artery bypass graft surgery

    Rev Bras Cir Cardiovasc

    (2010)
  • M. Mooney et al.

    “No more couch-potato!” Patients’ experiences of a pre-operative programme of cardiac rehabilitation for those awaiting coronary artery bypass surgery

    Eur J Cardiovasc Nurs

    (2007)
  • C.R. Gale et al.

    Framingham cardiovascular disease risk scores and incident frailty: the English longitudinal study of ageing

    Age (Dordr)

    (2014)
  • T. Fulop et al.

    Aging, frailty and age-related diseases

    Biogerontology

    (2010)
  • M.D. Pierri et al.

    The changing face of cardiac surgery patients: an insight into a Mediterranean region

    Eur J Cardiothorac Surg

    (2010)
  • D.H. Lee et al.

    Frail patients are at increased risk for mortality and prolonged institutional care after cardiac surgery

    Circulation

    (2010)
  • M. Singh et al.

    Influence of frailty and health status on outcomes in patients with coronary disease undergoing percutaneous revascularization

    Circ Cardiovasc Qual Outcomes

    (2011)
  • Cited by (0)

    Disclosure Statement: R.C. Arora has received honoraria from Mallinckrodt Pharmaceuticals and Abbott Nutrition and an unrestricted educational grant from Pfizer Canada unrelated to this article. The other authors have nothing to disclose.

    View full text