A Prehabilitation Program for Frail Patients Undergoing Cardiac Surgeries/Procedures (PREHAB)

The University of Hong Kong (HKU)

Status: Enrolling

Conditions: Transcatheter Aortic Valve Implantation; Heart Valve Replacement; Frailty; Coronary Artery Bypass Grafting

Treatments: Behavioral: Multi-component exercise programme; Behavioral: Structured preoperative education; Behavioral: Stress management; Behavioral: Nutritional optimization; Other: Attention Placebo

Study type: Interventional

Funder types: Other

Identifiers

NCT06323317

UW 21-405

Details and patient eligibility

About

The purpose of this study is to develop and evaluate a frailty-specific prehabilitation program for patients awaiting cardiac surgeries/procedures. The program aims to improve functional capacity, frailty level, cardiac-related physical functioning, health-related quality of life (HRQoL), psychological distress, major adverse cardiovascular and cerebral events (MACCE), hospital length of stay, and readmission rates.

Cardiovascular disease is a leading cause of disability and morbidity globally, particularly in older adults. Frailty, a geriatric syndrome commonly seen in cardiac patients, complicates their perioperative care and leads to worse outcomes.

Prehabilitation, which optimizes patients' physiological and functional capacities before surgery, has shown promise in general cardiac patients but requires a more comprehensive approach for frail individuals. This randomized controlled trial will recruit 50 Chinese adults awaiting elective cardiac surgeries/procedures in Hong Kong. Participants will be randomly assigned to either the intervention group, receiving a comprehensive prehabilitation program, or the control group, receiving routine preoperative care. Assessments will be conducted at baseline and at three postoperative time points.

The findings will contribute to our understanding of the impact of frailty on postoperative outcomes and help develop strategies to improve patient care. Ultimately, this study aims to reduce healthcare burdens associated with cardiac disease-related morbidity and disability.

Full description

Cardiovascular disease is a major cause of disability and morbidity worldwide. With advances in medical technology and care, patients with cardiovascular disease often live to an advanced age. In the older cohort, conditions particularly associated with age-related atherosclerosis and calcification dominate, such as coronary artery disease and valvular heart disease. Surgical interventions remain the treatment-of-choice for patients with advanced cardiac conditions. However, this vulnerable cohort is still afflicted by a higher risk of mortality, postoperative complications, and longer hospital stays, particularly those with frailty.

Frailty is a clinical condition characterized by reduced reserve capacity and excessive vulnerability to increased risk of adverse health outcomes when exposed to stressors. Its prevalence increases in the population with cardiovascular disease and is a significant prognostic indicator for predicting postoperative outcomes in cardiac patients. The best strategy to minimize the prognostic impacts of frailty on cardiac patients should be intervened at the preoperative stage, which may be achieved through prehabilitation.

Prehabilitation refers to preoperative interventions designed to optimize patients' physical and psychological readiness for surgery. The international guidelines of the Enhanced Recovery After Surgery Society (ERAS) suggest the prehabilitation for cardiac surgical patients should be exercise-based, supplemented with education, dietary modification, and psychological support. These components can prepare patients to withstand stressful events during surgery through reducing sympathetic over-activity and improving their physiological and functional capacities.

Accumulating evidence indicates the effectiveness of prehabilitation for general cardiac patients through respiratory muscle and aerobic training; however, few studies have investigated those with frailty, who are in greater need. Among the limited trial that particularly focus on frail patients, encouraging findings have been reported that preliminarily indicate their efficacy and safety profile. There are also some ongoing trials testing prehabilitation for frail cardiac patients registered in trial registries.

Despite the promising results, there are several major knowledge gaps in the studies of prehabilitation for frail cardiac patients. First, most of these trials are testing a single frailty-reversing strategy, either nutritional or exercise interventions, which are less comprehensive to address the urgent needs of surgical patients. Second, the protocols of those exercise programs are mainly aerobic-focused, deviating from the principles of exercise prescription suggested for frailty management. Third, all completed and ongoing trials are center-based using gymnasium equipment, which has several limitations that jeopardize the feasibility, availability, and effectiveness of the programs.

To conclude, more comprehensive and accessible prehabilitation programs are needed for frail cardiac patients to address their complex needs and improve their surgical outcomes. A hybrid approach, using eHealth to supplement in-person patient support, could offer a more practical and feasible solution. Further research is required to develop and evaluate such programs and to fill the knowledge gaps in prehabilitation for frail cardiac patients.

Enrollment: 50 estimated patients

Sex: All

Ages: 18+ years old

Volunteers: Accepts Healthy Volunteers

Inclusion criteria

1. A confirmed schedule for elective CABG, valve repair/replacement, or combined CABG and valve repair/replacement, or TAVI
2. Mild to moderate frailty at the time of recruitment, indicated by a Clinical Frailty Scale score between 4 and 6
3. At least 5 weeks of procedural waiting time
4. Physically fit for prehabilitation according to the surgeon/cardiologist's endorsement on a risk-assessment checklist
5. Living with family
6. Using an electronic device with internet access (patient/family).

Exclusion criteria

1. Impaired cognition (Abbreviated Mental Test score ≤6) or communication
2. With physical limitations to exercise

Trial design

Primary purpose: Prevention

Allocation: Randomized

Interventional model: Parallel Assignment

Masking: Single Blind

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50 participants in 2 patient groups, including a placebo group

Frailty-Specific Prehabilitation Program

Experimental group

Description:

Participants in the frailty-specific prehabilitation program (intervention group) will participate in a comprehensive prehabilitation programme comprising the following components: 1) structured preoperative education; 2) nutritional optimization; 3) stress management; and 4) exercise training. These four components are recommended by the international association as core elements of prehabilitation to optimize cardiac patients' physical and psychological capacity to withstand the challenges of cardiac surgical procedures. The prehabilitation will last for at least 4 weeks, and it will continue throughout the preoperative period.

Treatment:

Behavioral: Multi-component exercise programme

Behavioral: Nutritional optimization

Behavioral: Stress management

Behavioral: Structured preoperative education

Routine Preoperative Care

Placebo Comparator group

Description:

Participants in the control group will receive routine preoperative care provided by the clinical team, which includes unstructured patient education on the surgeries/procedures, and a brief session on the use of an incentive spirometer, breathing, and coughing exercise. Other perioperative care procedures will be implemented according to the existing clinical protocols.

Treatment:

Other: Attention Placebo