Can older, frail patients benefit from 'prehabilitation' before heart surgery?

The "new' approach -- components of "new" prehabilitation in cardiac surgery patients. Credit: Canadian Journal of Cardiology

High risk, frail heart patients might derive benefits from "prehabilitation," a strategy designed to enhance the recovery process after heart surgery by maintaining or improving the patient's overall physical and mental status before surgery, according to a group of eminent cardiac specialists writing in the Canadian Journal of Cardiology. The authors reviewed the current evidence regarding the benefits of prehabilitation and described two ongoing Canadian randomized controlled trials, examining prehabilitation in vulnerable heart disease patients.

28 jun 2018--The demand for surgical services is increasing as a result of an expanding "ageing population." Advances in healthcare practices and delivery have led to an increase in overall life expectancy. Currently, 8.5 percent of the world's population (approximately 620 million people) is older than 65 years of age. This percentage of older adults is projected to increase to 17 percent (1.6 billion) of the world's population by 2050. As a consequence, there has been an increase in the number of frail, older patients with advanced heart disease presenting for complex cardiac surgery procedures.
"The increasing number of older adults with a heart disease and subsequent increase in demand for heart procedures represents a veritable 'silver tsunami'," explained lead investigator Dr. Rakesh C. Arora, MD, Ph.D., from the University of Manitoba/St. Boniface General Hospital, Winnipeg, Manitoba, Canada. "Many of these patients have low physiological reserve. So when they undergo cardiac surgery, they experience a disproportionate decline in their health condition resulting in a long recovery time. In some instances, these vulnerable patients are discharged to a long-term care facility. In such cases, they experience poorer postoperative outcomes and worse quality of life despite a successful heart treatment or procedure. There is, therefore, an urgent need for the heart care team to ensure that the patients are not only liberated of cardiac disease symptoms, but also experience a better postoperative health-related quality of life, so they don't just survive, but thrive after their procedure."
In Canada, patients who require elective cardiac surgery are placed on a "waiting list" for up to two months. Previous investigations have established that patients on surgical waiting lists engage in minimal physical activity as they wait "in fear." There is some evidence to support the effectiveness of "prehabilitation" (prehab), a combination of exercise training, education, and social support, affecting patients' physical and psychological readiness for surgery, but these types of programs are not widespread. Prehab has the overarching goal to reduce postoperative complications and hospital length of stay as well as ideally improving the transition from the hospital back home. However, there is no formal consensus regarding what this should involve. While prehab has been used in patients undergoing bowel or bone surgery, it has not been widely considered for heart patients before surgery.
Dr. Arora and colleagues describe how new treatment protocols, also known as Enhanced Recovery Programs (ERPs), can help the heart team decide on the best treatment plan for vulnerable older adult patients before their procedures. The goals of an ERP are to maintain or improve the overall physical and mental status of the heart patient and reduce the impact of profound stress response following a cardiac procedure. They analyzed evidence from previous trials to support the use of prehab and evaluated how the NEW approach, a three-way approach including nutrition optimization, exercise training, and anxiety (worry) reduction (nutrition, exercise, and worry = NEW) may benefit heart patients.
Part of the barrier to the use of prehab in cardiac patients is the need for well done, multicenter, prospective studies. At present, there are two Canadian randomized controlled trials examining prehab in vulnerable cardiac patients that will hopefully provide new insights into the effectiveness of this intervention in the future:
The Pre-Operative Rehabilitation for Reduction of Hospitalization After Coronary Bypass and Valvular Surgery (PREHAB) is a Canadian multicenter trial that endeavors to provide safety information on the utility of prehab in this vulnerable patient population. The objective is 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.
A new multicenter study that will begin enrolling soon seeks to improve patient-centered outcomes and transitions of care in frail older adults undergoing transcatheter aortic valve replacement (TAVR). The PERFORM-TAVR trial (led by Dr. Jonathan Afilalo, McGill University) will use a combination of 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 procedure that will improve their recovery and diminish their likelihood of progressive deconditioning after a TAVR procedure.
"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," noted Dr. Arora. "The prehab ERP depends on collaboration and engagement of the patient, their caregivers, and heart team to ensure their success."

More information: "'NEW' Prehabilitation: A 3-way Approach to Improve Postoperative Survival and Health-Related Quality of Life in Cardiac Surgery Patients," Journal of Cardiology(2018). DOI: 10.1016/j.cjca.2018.03.020


Provided by Elsevier

Post-op mortality up for elderly with pre-heart op anxiety

Few elderly patients about to undergo cardiac surgery experience high levels of anxiety, but for those who do, there is a five-fold higher risk of postoperative major morbidity or mortality, according to research published in the Jan. 1 issue of The American Journal of Cardiology.

14 Jan 2013—Few elderly patients about to undergo cardiac surgery experience high levels of anxiety, but for those who do, there is a five-fold higher risk of postoperative major morbidity or mortality, according to research published in the Jan. 1 issue of The American Journal of Cardiology.

To examine the correlation between patient-reported anxiety and post-cardiac surgery mortality and major morbidity, Judson B. Williams, M.D., M.H.S., of the Duke University Medical Center in Durham, N.C., and colleagues conducted a prospective, multicenter cohort study—Frailty Assessment Before Cardiac Surgery—involving 148 elderly patients (mean age, 75.8 years) who were undergoing coronary artery bypass surgery and/or valve repair or replacement.

The researchers found that 7 percent of patients reported high levels of preoperative anxiety, with no difference based on type of surgery or Society of Thoracic Surgeons predicted risk. Preoperative anxiety independently predicted postoperative mortality or major morbidity, after adjustment for potential confounding variables (odds ratio, 5.1).

"Significant levels of patient-reported preoperative anxiety independently predicted a greater risk of in-hospital mortality or major morbidity in elderly patients undergoing cardiac surgery," the authors write. "Importantly, because high levels of anxiety are potentially modifiable, identifying these patients could provide an opportunity to increase psychological comfort and improve the clinical outcomes in this high-risk group."

More information: Abstract 
Full Text

Mild Cirrhosis is Not a Bar to Cardiac Surgery

NEW YORK, July 5 -- Cardiac surgery can be performed safely in many patients with mild liver cirrhosis, and in select patients with moderate cirrhosis, according to investigators here.
In a series of 27 patients with cirrhosis of the liver who underwent heart surgery, the operative mortality rate for patients with stage A disease, the mildest form, according to the Child-Turcotte-Pugh classification system was 11%, and the patients had an 80% one-year survival rate, reported Farzan Filsoufi, M.D., and colleagues, of Mount Sinai Hospital.
In contrast, four of six patients (67%) with Child-Turcotte-Pugh class C died during surgery, and only one survived a year, the authors reported in the July issue of Liver Transplantation.
Liver cirrhosis has been shown to be a major risk factor for death among patients undergoing abdominal surgery, with outcomes directly correlating with Child-Turcotte-Pugh disease stage, a measure originally used to estimate perioperative mortality in liver transplant candidates, but now also used to stage cirrhosis.
Although there are few such studies of heart surgery outcomes in patients with cirrhosis, observational reports have suggested that patients with liver disease fare worse during cardiac procedures, the authors noted.
"Patients with cirrhosis who require open heart surgical procedures are among the most challenging and complex patients seen in cardiac surgery," agreed Gonzalo Gonzalez-Stawinski, M.D., of the Cleveland Clinic, in an accompanying editorial.
"Liver disease results in physiologic derangements that are only exacerbated by surgery and cardiopulmonary bypass," Dr. Gonzalez-Stawinski said.
To get a better handle on the challenges of liver co-morbidity in heart surgery patients, the Mount Sinai investigators conducted a retrospective review of 4,952 patients who had cardiac surgery at their hospital from 1998 through 2004.
During that period, 20 men and 27 women with cirrhosis, mean age 58 + 10, underwent cardiac surgery, 18 with the use of cardiopulmonary bypass, and nine without.
The procedures included pericardiectomy, cardiopulmonary bypass grating (five performed off-pump), single or double valve replacement, and aortic repairs.
Ten of the patients had Child-Turcotte-Pugh class A disease, 11 had class B disease, and six had class C. The mean preoperative Model for End-stage Liver Disease (MELD) score was 14.2 + 4.2.
Seven patients (26%) died during surgery. When the deaths were stratified by Child-Turcotte-Pugh class, the authors found that death occurred in only 11% of patients with class A disease, compared with 18% of patients with class B, and 67% of patients with class C cirrhosis.
None of the deaths occurred in the five patients who had revascularization without the use of cardiopulmonary bypass.
One-year survival was 80% among patients with Class A disease, 45% in patients with class B cirrhosis, and 16% in patients with class C disease (P=0.02).
Postoperative complication rates followed a similar pattern, occurring in 22% of patients with class A disease, 56% with class B, and 100% of patients with class C disease.
The authors also found that the Child-Turcotte-Pugh classification was a better predictor of in-hospital death than the MELD score (P=0.02 versus P=0.065, respectively).
There was also a statistically significant inverse relationship between preoperative platelet count and hospital mortality (P<0.04), the authors noted. In addition preoperative platelet count was inversely related to the severity of cirrhosis as determined by the Child-Turcotte-Pugh class. There were no hospital deaths among patients with normal platelets count.
"Operative mortality remains high in Child-Turcotte-Pugh class C patients," the investigators wrote. "Careful patient selection is critical in order to improve surgical outcome in patients with cirrhosis."
In his editorial, Dr. Gonzalez-Stawinski wrote that the study affirms that surgeons need to be cautious in their approach to patients with cirrhosis of the liver.
"Filsoufi et al. report that the expected survival for Child-Pugh class B patients with cirrhosis is 50% at eight months. More importantly, the survival when considering patients with Child-Pugh class C is merely 50% at four months," he wrote. "These data are particularly important to take into account and explain to patients with cirrhosis at the time of consenting for surgery so that an informed decision is made without raising any false hopes or expectations."
Dr. Filsoufi and colleagues acknowledged that their study was limited by its retrospective, observational design, a patient population that was heterogenous and selected by referring specialists as potential heart surgery candidates, and the small sample size, which precludes an accurate assessment of the MELD score (a relative newcomer) as a tool for predicting cardiac surgery outcomes in patients with cirrhosis.
Neither study funding source nor author conflicts of interest were reported.Primary source: Liver TransplantationSource reference: Filsoufi F et al. "Early and Late Outcome of Cardiac Surgery in Patients With Liver Cirrhosis." Liver Transpl 2007; 13:990-995. Additional source: Liver TransplantationSource reference: Gonzalez-Stawinski G. "Early and Late Outcomes of Cardiac Surgery in Patients With Liver Cirrhosis." Liver Transpl 2007; 13:956.

Low-dose aspirin beats high-dose after cardiac surgery

Second study attributes long-term heart attack survival rates to rising use of cardiac drugs
The use of medicines to fight cardiovascular disease has been a primary focus of research in this area for the past several decades, as combinations of interventions and medicinal therapy have gradually begun to increase long-term survival rates. Two studies presented today at the American College of Cardiology's 56th Annual Scientific Session look at the measurable impact of the use of aspirin and other maintenance therapies, and one demonstrates that lower doses of therapies may prove to be just as beneficial while also lowering side effects. ACC.07 is the premier cardiovascular medical meeting, bringing together cardiologists and cardiovascular specialists to further breakthroughs in cardiovascular medicine.
"Cardiovascular disease is the leading cause of death today, and the major focus of research is to find better ways to help these patients through prevention, immediate intervention and long-term treatment regimens," said Douglas P. Zipes, M.D., Distinguished Professor of the Indiana University School of Medicine. "As we continue to discover the benefits of these therapies, we expect to see continued and measurable improvements in overall survival and quality of life."
Effects of Aspirin dose on Ischemic Events and Bleeding after Percutaneous Coronary Intervention (PCI): Insights from the PCI-CURE Study (Presentation Number: 2805-9)