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Strategies to improve postoperative outcomes after cardiac procedures are needed because older and frailer patients are being referred for surgery.
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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.
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Further high-quality research examining multimodal interventions in populations, such as those who are older, frail individuals, and women, is needed to provide additional
Prehabilitation: The Right Medicine for Older Frail Adults Anticipating Transcatheter Aortic Valve Replacement, Coronary Artery Bypass Graft, and Other Cardiovascular Care
Section snippets
Key points
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
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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.