Ischemic heart disease (IHD) is a major cause of death and disability worldwide, and accounts for more than 4 million deaths annually in Europe, placing a great strain on health care resources.1,2 Standard treatment in multivessel disease in patients with IHD is revascularization by coronary artery bypass grafting (CABG) surgery, a well-recognized treatment to relieve symptoms of angina and improve exercise capacity, quality of life, and survival rates.3 Advanced age, frailty, comorbidity, and physical inactivity are often present in patients with IHD awaiting CABG.4 These characteristics, as well as the physiological impact of having surgery, may lead to homeostatic disturbance, with patients experiencing postoperative physical symptoms and unable to return to independence.5,6 Undergoing CABG is a significant life event, with an important psycho-emotional impact on patients and their families, where patients can experience mood swings and difficulty completing the transition process and reorientation in life.7 Rates of cognitive decline as high as 41% have been reported following CABG.8 Poor physical and nutritional status among elderly patients with limited functional reserve who undergo surgery may lead to both short- and long-term harmful effects postoperatively.9
Most patients scheduled for elective CABG wait at home and undergo little or no physical training or other interventions in the lead up to their operation. Evidence shows that patients deteriorate functionally and psychologically during this period prior to surgery.4,10 Furthermore, studies show that the time spent waiting for cardiac surgery is a period of great uncertainty for the patient.10,11 There is heightened anxiety regarding physical activity, mainly because of patients’ current cardiac conditions or diagnosis.11 Patients engage in minimal physical activity as they wait, due to concerns about the operation itself, potential complications, physical restrictions, and the well-being of significant others.12 Subsequent physical inactivity characterized by sedentary behavior and lifestyle may add to the underlying IHD, which is a major risk factor for coronary artery disease.13 The cardiovascular system is sensitive to changes in activity levels. Sedentary behavior and physical inactivity are modifiable cardiovascular disease risk factors that can lead to physical deconditioning and an increased level of frailty.14,15 As patients age, comorbidities are more common, and innovative strategies are required to alleviate the risk of adverse outcomes in patients undergoing cardiac surgery.16
Strategies to improve outcomes from surgery and accelerate return to baseline levels have traditionally focused on the intra-operative and postoperative periods; however, this may not be an opportune time to commence lifestyle changes. After CABG, patients may struggle with loss of appetite, fatigue, pain, depression, and postoperative complications, particularly at the pulmonary level.15 Therefore, the period before surgery might offer an opportunity for preoperative interventions that could improve the safety and outcome of their surgical intervention and improve patients’ motivation in postoperative rehabilitation and recovery time.17 The preoperative period may be a more salient time to optimize patients’ physical and psychological status, as they are generally in better condition compared with the acute postoperative period.15 Preoperative interventions, also referred to as “prehabilitation,” increase patients’ functional reserve, including physical, nutritional, metabolic, and mental components in anticipation for surgery.9,18
Prehabilitation was initially supported in animal models.18 It reflects a proactive process of enhancing an individual's functional capacity between diagnosis and scheduled surgery to improve physiological capacity to withstand the upcoming stress of surgery and thus avoid complications. It is hypothesized that these patients who participate in prehabilitation will have reduced postoperative functional decline compared with patients who remain inactive while waiting for surgery.18
Prehabilitation may include, among other things, exercise interventions, nutrition control, behavioral changes, and cognitive training.18 In recent years, numerous studies on prehabilitation have been carried out in gastrointestinal cancer, orthopedic, and urologic surgeries.19,20 A systematic review and meta-analysis concluded that, in patients undergoing surgery, a total body prehabilitation intervention tended to reduce length of stay and possibly improve postoperative pain and physical function compared to standard care; this was mainly related to orthopedic populations.20 Furthermore, prehabilitation has been shown to reduce the need for postoperative rehabilitation.21 A meta-analysis showed a significant increase in pulmonary function with positive increases in exercise capacity in patients with lung cancer who participated in preoperative exercise training.22
Prehabilitation before CABG is currently not widely adopted and has been described as a combination of exercise training, education, and social support affecting patients’ physical and psychological readiness for surgery intended to reduce postoperative complications and hospital length of stay (LOS).15,17,23 A rehabilitation-like program with different preoperative interventions delivered before cardiac surgery, seems to play a role in preventing postoperative cognitive dysfunction.24 A recent article by the Enhanced Recovery After Surgery (ERAS) Society presented expert consensus recommendations for preoperative strategies to optimize physical readiness for surgery among patients undergoing cardiac surgery; however, psychological recommendations are sparse.25 Efforts to reduce perioperative fear and to engage patients are only recommended in terms of patient education through a few online or application-based approaches.25 A qualitative descriptive pilot study identified the need to make prehabilitation programs more patient-centered and to design more effective therapeutic strategies tailored to meet patients’ specific needs in overcoming program non-adherence.26 Preoperative cardiac rehabilitation may be safe, effective, meaningful, and feasible; however, there is limited evidence regarding patients’ experiences and perceptions of those interventions.27
An initial search in May 2019 in MEDLINE (PubMed), CINAHL, Cochrane Library, PROSPERO, and the JBI Database of Systematic Reviews and Implementation Reports indicated that no scoping reviews on this topic were available or currently under development. This preliminary search was performed to avoid evidence duplication following the recommendations of Peters et al.28 One review from 2019 provided an overview of the evidence, supporting preventive programs and therapies delivered before cardiac surgery. The results were based on a narrow literature search in only one database with few keywords. The authors concluded that comprehensive and individualized bundles of preoperative interventions are necessary and may best be delivered as a part of routine preoperative care.16 They did not conduct a meta-analysis, nor did they focus specifically on patients’ experiences of participating in prehabilitation.
Because of the increasing number of patients planning surgery, it is paramount to improve their preoperative health status in order to optimize postoperative outcomes. This current scoping review differs from previous reviews in that it will have a more comprehensive and exhaustive literature search and, furthermore, it will include feasibility and patients’ experiences of participating in prehabilitation. It is intended to inform the future development of a systematic review and the development of evidence-based clinical practice guidelines. Therefore, the objective of this scoping review is to identify and map existing evidence of preoperative interventions in adult patients awaiting elective CABG in order to optimize postoperative physical and psychological health outcomes. This scoping review further intends to explore existing information about the feasibility of such interventions and patients’ experiences with them. All types of pre-operative interventions will be chosen in this scoping review as patients placed on a waiting list for CABG-surgery can be waiting at home, in a care facility of some kind, or in hospital. It will be conducted in accordance with the methodology for JBI scoping reviews28 whose guidance for the conduct and reporting of scoping reviews has been adhered to in the preparation of the present protocol. It will be followed throughout the ensuing review.
- i) Which preoperative interventions have been carried out to optimize postoperative physical and psychological health outcomes for adult patients awaiting CABG surgery?
- ii) What has been reported on the feasibility of preoperative interventions (eg, adherence rates, drop out rates, recruitment problems, reported barriers for the intervention)?
- iii) What is known about patients’ experiences of the interventions (eg, satisfaction or concerns)?
This scoping review will consider studies that include male and female adult patients with IHD who are at home awaiting elective CABG.
The core concept is the content, nature, and outcomes of any preoperative intervention referred to as “prehabilitation” in adult patients awaiting elective CABG, with the objective of optimizing physical and psychological health status to reduce complications after surgery. Papers reporting on the feasibility of these interventions will be included as well as papers that report on patients’ experiences with these interventions.
Studies conducted in any setting – including the patient's home, community location, care facility, or in hospital – while the patient is awaiting CABG will be considered in this review, with no restrictions placed on the geographical location or culture.
Types of sources
This scoping review will consider both experimental and quasi-experimental study designs including randomized controlled trials, non-randomized controlled trials, before and after studies, and interrupted time-series studies. In addition, analytical observational studies including prospective and retrospective cohort studies, case-control studies, and analytical cross-sectional studies will be considered for inclusion. This review will also consider descriptive observational study designs including case series, individual case reports, and descriptive cross-sectional studies for inclusion. Qualitative studies that focus on qualitative data including, but not limited to, designs such as phenomenology, grounded theory, ethnography, qualitative description, action research, and feminist research will be considered. In addition, systematic reviews that meet the inclusion criteria will also be considered. Text and opinion papers will be considered for inclusion in this scoping review.
The review will be conducted in accordance with JBI methodology for scoping reviews.28
The search strategy aims to find both published and unpublished studies. A three-step search strategy will be utilized for this review.28 An initial limited search of MEDLINE and CINAHL was undertaken with a research librarian to identify articles on the topic. The text words contained in the titles and abstracts of relevant articles and the index terms used to describe the articles were used to develop a full search for MEDLINE (PubMed), which is shown in Appendix I. The search strategy, including all identified keywords and index terms, will be adapted for each included information source. The reference lists of all included studies will be screened for additional studies. Studies published in English, German, Danish, Swedish, and Norwegian will be considered for inclusion in this review. Data from non-English studies will be translated into English before presentation in the final scoping review, and the original text will be provided in brackets. The translation will be completed in a side-by-side procedure together with a professional translator.29 Databases will be searched from their inception. Not limiting by date will ensure that the search is as wide as possible. Where relevant, the reviewers will contact authors of primary studies or reviews for further information.
The databases to be searched include MEDLINE via PubMed, CINAHL via EBSCO, PsycINFO via EBSCO, Embase via Ovid, Web of Science via Clarivate, Scopus via Elsevier, Cochrane via Wiley, PEDro (https://pedro.org.au/), SveMed+ (https://svemedplus.kib.ki.se/). Sources of unpublished studies and gray literature to be searched include MedNar, OpenGrey, NICE Evidence Search, Google Scholar, and SIGN.
Following the search, all identified citations will be collated and uploaded into EndNote X9 (Clarivate Analytics, PA, USA) and duplicates removed. Titles and abstracts will then be screened by two independent reviewers (DBO and MWN) for assessment against the inclusion criteria for the review. Potentially relevant studies will be retrieved in full and their citation details imported into JBI System for the Unified Management, Assessment and Review of Information (JBI SUMARI; JBI, Adelaide, Australia). The full text of selected citations will be assessed in detail against the inclusion criteria by two independent reviewers. Reasons for exclusion of full-text studies that do not meet the inclusion criteria will be recorded and reported in the scoping review. Any disagreements that arise between the reviewers at each stage of the study selection process will be resolved through discussion, or by involving a third reviewer (PUP). The results of the search will be reported in full in the final scoping review and presented in a Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) flow diagram.30
Data will be extracted from papers included in the scoping review by two independent reviewers (DBO and MWN) using a data extraction tool developed by the reviewers. The data extracted will include specific details about the population, concept, context, study methods, and key findings relevant to the review objective. A draft charting table is provided (Appendix II). The draft data extraction tool will be modified and revised as necessary during the process of extracting data from each included study. Modifications will be detailed in the full scoping review report. Any disagreements that arise between the reviewers will be resolved through discussion or with a third reviewer. Authors of papers will be contacted to request missing or additional data, where required.
Data analysis and presentation
The extracted data will be presented in diagrammatic or tabular form in a manner that aligns with the objective of this scoping review and will be supported by narrative descriptions of the data. A summary will accompany the tabulated and charted results, and will describe how the results relate to the review's objective and questions.28 Further, themes according patients’ experiences identified from qualitative studies related to the individual interventions or programs will be presented in a separate column, together with the other tabulated and charted results, and supported by narrative descriptions.
Appendix I: Search strategy
Search conducted March 31, 2020
Appendix II: Data extraction forms
Extraction of findings from systematic reviews
Extraction of findings from primary research
Extraction of findings from qualitative studies
Vibeke Rauff Witt, research librarian of the Medical Library, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark, for assistance with the literature search and strategy.
Eamonn McDonagh for assistance with language revision.
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