‘NEW’ Prehab Prior to Cardiac Surgery May Improve Outcomes

Researchers are investigating the effects of “prehabilitation,” using wait times prior to cardiac surgery as an opportunity to improve postoperative outcomes for frail older adults.

A three-pronged approach called NEW, a component of the enhanced recovery protocols (ERPs), targets nutritional status (N), exercise capacity (E), and worry reduction  to support the growing number of older patients undergoing complex cardiac procedures.

A new review examines the evidence supporting the NEW approach to prehabilitation in these patients as well as barriers to implementation, including the need for further research.

“The fundamental premise behind prehab ERP is that improving patients’ functional reserve before their procedure will improve postoperative outcomes that are important to older adults, including preserving mental and functional independence and enhancing postoperative recovery,” lead author Rakesh C. Arora, MD, PhD, University of Manitoba, St. Boniface Hospital, Winnipeg, told theheart.org | Medscape Cardiology.

The article was published in the July issue of the Canadian Journal of Cardiology.

A Growing Need for Prehabilitation

Medical advancements have expanded overall life expectancy and the demand for cardiac surgery among the aging population has increased. The authors note that 8.5% of the world’s population is older than 65 years of age, with that number projected to increase to 17% by 2050.

An increase in older adults with heart disease as well as related surgeries can lead to “comorbid-associated higher vulnerability with associated deconditioning” resulting in a problematic recovery process and less than ideal postoperative outcomes, they write.

“This places some patients, particularly those who are more frail, at a higher vulnerability to poorer postoperative outcomes and a complicated recovery process after cardiac surgery,” says Arora. “In addition, such patients experience a reduced quality of life as a result of loss of the ability to independently perform activities of daily living.”

In Canada, patients who require elective cardiac surgery are placed on a waiting list for up to 2 months. This waiting period can often result in further inactivity because of cardiac symptoms and anxiety, which results in further deconditioning, the authors say.

The goal of prehab is to “reduce postoperative complications and hospital length of stay as well as ideally improving the transition from the hospital back home.”

Prehab has been effective in supporting the patients’ physical and psychological readiness for surgery, the authors note. “We’re taking patients before their operation and putting them through the same program they would have after their operation,” says Arora.

Prehab has been used with bone and bowel surgery but has not been widely used for patients with cardiac conditions.

The Components of NEW

Current evidence shows that improving a patient’s physical functioning, providing adequate nutrition, and focusing on psychological and mental health needs are important factors in achieving postoperative outcomes, the authors write.

“The ideal prehab intervention would, therefore, target the biological, psychological, and social domains of frailty that can all limit recovery after the stress of cardiac surgery,” they note.

The NEW approach, says Arora, “may improve the patient journey through their operation and alleviate the surgical stress-related health deconditioning.”

The approach integrates dietary modification to counter protein-energy malnutrition, individually tailored exercise intervention to improve baseline functional capacity, and alleviate preoperative anxiety and stress.

Arora concludes that although there is some evidence to support the effectiveness of prehab, the programs are not widespread. There are several reasons for this, including potential patient-related issues. “As opposed to a pill or a lab test, prehab requires a substantial commitment from the patient (and potentially their caregivers) as well as resources from the healthcare team,” the authors write.

However, Arora says, “fundamentally, we need more research to answer some important questions,” not least of which is the safety of exercise-based interventions in these high-risk cardiac surgery patients which, the authors note, “has not yet been clearly shown.”

Other questions include better defining the target populations who may benefit most from prehab and examining specific characteristics of a prehab program including whether it is necessary to include all three exercise, nutritional, and anxiety-reduction components.

“Trying to protect people’s functional independence so they don’t just survive but thrive after the surgery is what we’re trying to do with the paradigm shift of care of older adults undergoing these procedures,” says Arora.

At present there are two Canadian trials studying prehab in older adult cardiac patients.

The multicenter Pre-Operative Rehabilitation for Reduction of Hospitalization After Coronary Bypass and Valvular Surgery (PREHAB) trial provides safety information for using prehab in older patients to “evaluate the feasibility of exercise intervention before elective cardiac surgeries and its efficacy in improving postoperative outcomes including length of hospitalization, health-related outcomes, and health-related quality of life outcomes.”

The Protein and Exercise to Reverse Frailty in Older Men and Women Undergoing Transcatheter Aortic Valve Replacement (PERFORM-TAVR) trial, led by Jonathan Afilalo, MD, McGill University, Montreal, Quebec, set to begin soon, will study “patient outcomes and transitions for frail older adults undergoing TAVR,” the authors note.

The study will use a “home-based physical activity program that combines walking and strength-building exercises under the supervision of a trained physiotherapist and nutritional supplementation that seeks to empower patients to adopt self-care behaviors before the procedures that will improve their recovery and diminish their likelihood of progressive deconditioning after a TAVR procedure.”

Arora has received an unrestricted educational grant from Pfizer Canada and honoraria from Mallinckrodt Pharmaceuticals for work unrelated to the article. The other authors have reported no relevant financial relationships.

Can J Cardiol. 2018;34:839-849. Abstract

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