Early initiation of poststernotomy cardiac rehabilitation exercise training is effective and safe
1. Early cardiac rehabilitation following cardiac surgery involving median sternotomy was non-inferior to usual-care cardiac rehabilitation, suggesting similar levels of effectiveness and safety amongst both groups.
Evidence Rating Level: 1 (Excellent)
Study Rundown: There have been significant improvements in post-operative care and reduced complication rates in patients who have cardiac surgery requiring median sternotomy. Despite this, cardiac rehabilitation is often not initiated until six weeks post-sternotomy due to concerns regarding sternal healing following surgery. There remains ambiguity around indications for activity following sternotomy with no clear clinical recommendations, although some evidence does suggest that overly restrictive sternal precautions may contribute to poor health outcomes and subsequently support the earlier initiation of cardiac rehabilitation. As such, this randomized clinical trial aimed to investigate the effectiveness and safety of cardiac rehabilitation (CR) started two weeks after sternotomy (early CR) compared to CR started six weeks after (usual-care CR). A total of 158 participants from the United Kingdom who had coronary artery bypass graft and mitral or aortic valve replacement, recovering from median sternotomy were included. Participants were randomly assigned to early CR or usual-care CR groups and change in 6-minute walk test distance from baseline to after CR was assessed in all participants. The results of this study showed that early CR was not inferior to usual-care CR. In conclusion, this trial indicates that in patients receiving cardiac surgery involving median sternotomy, early cardiac rehabilitation is just as effective as usual-care cardiac rehabilitation. However, as this study was only conducted in two hospitals within the United Kingdom, these findings may not be generalizable to the greater population. Nonetheless, this study offers insights into effectiveness and safety of the earlier initiation of CR and warrants further research investigating long-term health outcomes and psychosocial benefits of earlier CR.
Click here to read the study in JAMA Cardiology
In-Depth [Randomized Control Trial]: The present study used data from patients aged 18 to 90 who had coronary artery bypass graft and cardiac valve replacement or repair, recovering from median sternotomy at two hospitals in the United Kingdom. To examine the efficacy and safety of early cardiac rehabilitation compared to usual-care cardiac rehabilitation following cardiac surgery involving sternotomy, 158 participants recovering from sternotomy were included. Early cardiac rehabilitation (CR) was started at two weeks and usual-care cardiac rehabilitation was started at six weeks. In both groups, participants completed eight weeks of twice-weekly, one-hour CR exercise training. The usual-care CR group completed a warm-up with light cardiovascular and mobility exercises followed by moderate-intensity continuous cardiovascular exercises such as cycling, rowing, or walking on the treadmill. The early CR group began rehabilitation with an individualized exercise program dictated by their current level of fitness and post-surgery symptoms; these participants were slowly transitioned to usual-care CR exercises once they were able to tolerate this. Participants were randomly assigned to either early CR or usual-care CR. Primary outcomes for this study included change in the six-minute walk test distance from baseline to after rehabilitation. Secondary outcomes included safety, functional fitness, and quality of life. Statistical analyses included linear regression. The results of this study showed that early CR was not inferior to usual-care CR. The noninferiority margin was 35m and the average change in 6-minute walk test distance was 28m higher in the early CR group compared to the usual-care CR group (95%CI, -11-66, P=0.16). Additionally, there was no statistically different change in safety, functional fitness, and quality of life between the two groups. This paper confirms that starting cardiac rehabilitation as early as two weeks post-sternotomy is as effective and safe as beginning CR six weeks after. Further research investigating benefits of early CR on psychosocial health, long-term health outcomes, and overall quality of life may be helpful in the prognosis of cardiac surgery patients receiving sternotomy.
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