‘Teleprehabilitation’ Before Cardiac Surgery Improves the Outcomes That Follow

LISBON, Portugal—Patients who undergo a cardiac prehabilitation prior to elective surgery or procedures via a smartphone app have a lower incidence of major adverse cardiovascular events (MACE) through 1 year, a benefit driven by a decrease in rehospitalizations, according to new randomized data.

“Cardiac surgery saves lives, no doubt, but what if we could improve patient outcomes by starting cardiac rehabilitation programs already weeks before the outcome of surgery?” said Bart Scheenstra, MD (Maastricht University Medical Center, the Netherlands), who presented the findings during a late-breaking science session at the European Association for Cardio-Thoracic Surgery (EACTS) 2024 meeting. “We already know from previous research in cardiac prehabilitation that it improves quality of life, it reduces length of hospital stay, and it reduces complications, but we do not know what the effect is of these programs on major adverse cardiovascular events.”

Much like cardiac rehab, the “teleprehabilitation” program focuses on smoking cessation, nutrition, patient education, inspiratory muscle training, and functional exercise training, but instead it is undertaken online prior to a procedure.

Driven by Fewer Rehospitalizations

For the study, simultaneously published in the Journal of the American College of Cardiology, Scheenstra and colleagues randomized 394 patients (mean age 66 years; 75% male; mean EuroSCORE II 1.1) scheduled for elective cardiac surgery and procedures to receive personalized prehabilitation from a multidisciplinary team through an app for about 6-8 weeks prior to surgery or usual care. As the trial was conducted from May 2020 to August 2022 during the COVID-19 pandemic, the study was conducted online and not in a formal rehabilitation center.

About 40% of patients were undergoing coronary surgeries, with another 40% slated for valvular surgeries and 20% receiving other kinds of procedures. Slightly more than half (55%) had a sternotomy, but the trial also included patients undergoing minimally invasive surgeries as well as transcatheter procedures like TAVI.

The primary outcome of MACE—a composite of cardiovascular death, MI, stroke, hospitalization for heart failure or other life-threatening cardiac events, and earlier or repeated intervention—was reported less frequently in the teleprehabilitation group than in controls from randomization through 1-year post-op (16.8% vs 25.5%; P = 0.032). The benefit observed with the prehabilitation program was primarily driven by fewer repeat hospitalizations (3.0% vs 8.7%; P = 0.019).

Notably, the difference was no longer significant after adjustment for intervention type, smoking status, LVEF, and NYHA class (adjusted HR 0.68; 95% CI 0.44-1.06). However, when the analysis was isolated to nontranscatheter procedures, teleprehabilitation was significantly associated with improved outcomes (adjusted HR 0.59; 95% CI 0.35-0.98). There were also significant effects observed in female patients (OR 0.312), patients with a higher EuroSCORE II (OR 0.492), and those receiving cardiac surgery (OR 0.49).

Quality of life as measured by the EQ-5D-5L was also improved at 1 year with teleprehabilitation compared with controls (P = 0.002).

By the time of surgery, the prehab program reduced the number of active smokers as well as those with elevated pulmonary risk scores and elevated depression scores. The researchers noted no differences between the study group and controls in postoperative hospital length of stay, postoperative complications, physical fitness, obesity, or malnutrition.

‘Across the Board’ Benefit

Asked if he had expected the intervention to provide more benefit in a specific subgroup of patients, Scheenstra said it’s logical to think that the highest-risk patients—those with the most modifiable risk factors—would benefit the most.

“But what we've learned also from prehabilitation in other fields, like abdominal surgery and other surgery, is that the benefit seems to be across the board,” he said. “Of course, there's the marathon runner who is perfectly fit and mentally healthy who will not have benefit.”

With about 98% of patients having at least one modifiable risk factor, Scheenstra said the logical thing to do is “screen everyone and then decide together with the team and the patient whether you want to start a prehabilitation program . . . and if it might benefit you.”

One of the challenges with prehabilitation is balancing the advantages associated with the program against any potential risks with waiting to do the surgery. A tough question surgeons might have to ask, Scheenstra said, is: “Do we want to postpone the surgery for the benefits we might achieve with this?”

He was also asked about the potential for reducing obesity before surgery. While the advent of GLP-1 receptor agonists has now changed the conversation about cardiac surgery, that wasn’t necessarily the case when the trial was running, Scheenstra said. “We did not see any effect in this trial on BMI, for example,” he said. “We also cannot expect that with what we did.”

But he agreed that future trials should look at incorporating weight-loss medications into prehabilitation before cardiac surgery and see what effect they might have on outcomes.

Support for Surgical RCTs

Patrick Myers, MD (Lausanne University Hospitals, Switzerland), who serves as the secretary general of EACTS and co-moderated the session, told TCTMD the study is an example of “a high-quality, randomized controlled trial that's designed and run by surgeons to improve the outcomes of surgical patients.”

It’s been unusual in the past to see randomized controlled trials in surgery be presented at meetings like EACTS, much less be published in high-impact journals, Myers pointed out.

Major cardiology conferences “all have joint sessions [with] the New England Journal of Medicine, JACC, Circulation, et cetera, and we don't have that in surgery, really. That hasn't been done until now. And here we have a submission that was considered to be of high enough quality to merit, first of all, being published in JACC, but also being published as a simultaneous publication,” he said. “It just shows the quality of the work that's being done here in Europe by our surgeons.”

The study findings are important for cardiologists, anesthetists, and intensivists to know about, Myers said, because it shows “how to optimize the patient profile before they get to the operation.”