A randomised controlled trial of prehabilitation in patients undergoing elective cardiac surgery

Abstract

Summary The feasibility, safety and efficacy of prehabilitation in adult patients awaiting elective cardiac surgery are unknown. A total of 180 participants undergoing elective cardiac surgery were allocated randomly to receive either standard pre‐operative care or prehabilitation, consisting of pre‐operative exercise and inspiratory muscle training. The primary outcome was change in six‐minute walk test distance from baseline to pre‐operative assessment. Secondary outcomes included change in inspiratory muscle strength (maximal inspiratory pressure); sarcopenia (handgrip strength); quality of life and compliance. Safety outcomes were pre‐specified surgical and pulmonary complications and adverse events. All outcomes were assessed at baseline; at pre‐operative assessment; and 6 and 12 weeks following surgery. Mean (SD) age was 64.7 (10.2) years; 33/180 (18%) were women. In total, 65/91 (71.4%) participants who were allocated to prehabilitation attended at least four of eight supervised in‐hospital exercise classes; participants aged > 50 years were more likely than younger participants to attend (odds ratio (95%CI) of 4.6 (1.0–25.1)). Six‐minute walk test was not significantly different between groups (mean difference (95%CI) ‐7.8 m (‐30.6–15.0), p = 0.503) in the intention‐to‐treat analysis. Subgroup analyses based on tests for interaction indicated improvements in six‐minute walk test distance were larger amongst sarcopenic patients in the prehabilitation group (p = 0.004). Change in maximal inspiratory pressure from baseline to all time‐points was significantly greater in the prehabilitation group, with the greatest mean difference (95%CI) observed 12 weeks after surgery (10.6 cmH2O (4.6–16.6) cmH2O, p < 0.001). There were no differences in handgrip strength or quality of life up to 12 weeks after surgery. There was no significant difference in postoperative mortality (one death in each group), surgical or pulmonary complications. Of 71 pre‐operative adverse events, six (8.5%) were related to prehabilitation. The combination of exercise and inspiratory muscle training in a prehabilitation intervention before cardiac surgery was not superior to standard care in improving functional exercise capacity measured by six‐minute walk test distance pre‐operatively. Future trials should target patients living with sarcopenia and include inspiratory muscle strength training.

The prevalence and impact of sarcopenia in older cardiac patients undergoing inpatient cardiac rehabilitation – results from a prospective, observational cohort pre-study

“…Both results are in line with the results found in the current literature [ 56 – 59 ]. A recently published randomized control trial showed that a prehabilitation program before elective cardiac surgery improved 6MWD significantly in the subgroup of sarcopenic patients [ 60 ]. These results indicate that cardiac prehabilitation programs should include exercises to increase endurance and mobility to prepare especially older patients with sarcopenia for the procedure and the convalescent phase of relative inactivity.…”

Fitter, better, sooner: prehabilitation and clinical outcomes in cardiac surgery

“…The study by Akowuah et al. is, therefore, an important addition to the published literature [3]. The authors conducted a randomised controlled trial in 180 patients undergoing cardiac surgery, assessing feasibility, safety and efficacy of exercise and inspiratory muscle training prehabilitation interventions.…”

“…In With regard to prehabilitation research in cardiac surgery, there is an accompanying qualitative study by Harrison et al [4]. The authors have concentrated on the experiences of patients and staff enrolled in the cardiac prehabilitation trial conducted by Akowuah et al [3]. Whilst this is a small study, with 16 male patients and eight staff members included, it is important as it explores the fears cardiac patients and staff have about exercise in this highrisk group, which may directly impact on the feasibility and efficiency of the intervention.…”

“…Whereas for decades cardiac rehabilitation has been an established intervention to improve outcomes in patients with heart disease, the general knowledge about prehabilitation, clinical experience and potential benefits in patients having cardiac surgery remain limited [2]. We therefore welcome the two articles published in Anaesthesia about prehabilitation in cardiac surgery: a randomised controlled trial of prehabilitation in elective patients undergoing cardiac surgery (PrEPS trial) [3] and a nested qualitative study about the experience of patients and staff enrolled in the PrEPS trial [4].…”