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.
