Frailty and Exercise Training: How to Provide Best Care after Cardiac Surgery or Intervention for Elder Patients with Valvular Heart Disease

Abstract

The aim of this literature review was to evaluate existing evidence on exercise-based cardiac rehabilitation (CR) as a treatment option for elderly frail patients with valvular heart disease (VHD). Pubmed database was searched for articles between 1980 and January 2018. From 2623 articles screened, 61 on frailty and VHD and 12 on exercise-based training for patients with VHD were included in the analysis. We studied and described frailty assessment in this patient population. Studies reporting results of exercise training in patients after surgical/interventional VHD treatment were analyzed regarding contents and outcomes. The tools for frailty assessment included fried phenotype frailty index and its modifications, multidimensional geriatric assessment, clinical frailty scale, 5-meter walking test, serum albumin levels, and Katz index of activities of daily living. Frailty assessment in CR settings should be based on functional, objective tests and should have similar components as tools for risk assessment (mobility, muscle mass and strength, independence in daily living, cognitive functions, nutrition, and anxiety and depression evaluation). Participating in comprehensive exercise-based CR could improve short- and long-term outcomes (better quality of life, physical and functional capacity) in frail VHD patients. Such CR program should be led by cardiologist, and its content should include (1) exercise training (endurance and strength training to improve muscle mass, strength, balance, and coordination), (2) nutrition counseling, (3) occupational therapy (to improve independency and cognitive function), (4) psychological counseling to ensure psychosocial health, and (5) social worker counseling (to improve independency). Comprehensive CR could help to prevent, restore, and reduce the severity of frailty as well as to improve outcomes for frail VHD patients after surgery or intervention.

Geriatric or cardiac rehabilitation? Predictors of treatment pathways in advanced age patients after transcatheter aortic valve implantation

“…Due to the demographic shift, a recent call to action from the European Association of Preventive Cardiology Cardiac Rehabilitation Section promotes the investigation of frail patients also in cardiac rehabilitation settings and recommends to become familiar with some of the tools to recognize and evaluate the severity of this condition [27]. In addition, a recent review concludes that frailty assessments in CR settings should be based on functional, objective tests and should have similar components as tools for risk assessment (e. g. mobility, muscle mass and strength, independence in daily living, cognitive function, nutrition as well as anxiety and depression evaluation) [28].…”

Secondary prevention through comprehensive cardiovascular rehabilitation: From knowledge to implementation. 2020 update. A position paper from the Secondary Prevention and Rehabilitation Section of the European Association of Preventive Cardiology

“…111 Several instruments, encompassing the physical, nutritional, cognitive and psychosocial domains of health, have been used to evaluate frailty in community living elderly populations or in hospital settings. [112][113][114] Frailty has been described in 10-50% of elderly patients admitted after an acute cardiac event, and it has proved to be an independent prognostic indicator even in these patients. 115 However, due to selection bias and to several barriers, frail patients, potential candidates to cardiac rehabilitation, are poorly represented in cardiac rehabilitation studies.…”

Association between frailty and self-reported health following heart valve surgery

“…A complex care plan of frail patients should be incorporated in the discharge planning, and frail surgical valve patients potentially require closer follow-up and targeted interventions to improve overall outcomes, frailty status and self-reported health. Also, to prevent further deterioration in physical capacity, an exercise plan, early in-hospital rehabilitation, and referral for rehabilitation following discharge should gain increased focus [34] , [35] . Despite the prognostic and therapeutic relevance, frailty is not routinely assessed among patients undergoing open heart valve surgery and the current study highlight how ongoing efforts must focus on improving both the measurement and the treatment of this health state – to improve the overall health outcome of the valve patient.…”