Cardiac Rehabilitation as Therapeutic Strategy After Coronary Artery Bypass Grafting

Cardiac rehabilitation effectively improves exercise tolerance, reduces readmission rates and improves long-term prognosis in patients with cardiovascular disease (CVD).^1,2 Several studies have shown that exercise training effectively suppresses neurohumoral factors and inflammatory cytokines, and also improves vascular endothelial function and musculoskeletal metabolism.^3–5 In addition, a disease management program implemented by a multidisciplinary team as part of a comprehensive cardiac rehabilitation program has been recognized as useful for secondary prevention in patients with CVD.⁶ Currently, a comprehensive cardiac rehabilitation program is internationally recommended in guidelines for coronary artery disease as well as for heart failure.^7–9 Recently, “The Standard Rehabilitation Program for Heart Failure” has been released to promote appropriate cardiac rehabilitation for heart failure throughout Japan.¹⁰

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In the 1970 s, coronary artery bypass grafting (CABG) was introduced in Japan, and there are currently more than 10,000 procedures performed in this country.¹¹ Adachi et al reported that after CABG patients improved exercise tolerance of peak oxygen uptake (peak V̇O₂) with 2 weeks of exercise-based cardiac rehabilitation.¹² Takeyama et al showed that the index of parasympathetic activity and exercise tolerance was improved by 3 weeks of exercise-based cardiac rehabilitation.¹³ Although there are many reports that show the short-term effects of exercise-based cardiac rehabilitation in patients after CABG, such as the reports above,^12,13 the existing evidence of the efficacy of cardiac rehabilitation on the long-term prognosis in patients after CABG is limited. To date, no studies have aimed at assessing the effect of active cardiac rehabilitation participation on exercise capacity and long-term prognosis in patients after CABG. CABG is generally selected for patients with advanced arteriosclerosis, such as those with severe calcification in the coronary arteries or severe multivessel lesions, compared with percutaneous coronary intervention. Therefore, it remains a major challenge to determine whether cardiac rehabilitation can avoid cardiac accidents and improve the long-term prognosis of patients after CABG.

In this issue of the Journal, Origuchi et al¹⁴ examine the effect of outpatient cardiac rehabilitation on exercise capacity and long-term prognosis in patients after CABG in a multicenter cohort. Their study consisted of 240 patients who actively participated in outpatient cardiac rehabilitation and 106 patients who did not. The primary endpoint was a major adverse cardiac event (MACE), defined as all-cause death, acute myocardial infarction, or unplanned rehospitalization for unstable angina or worsening heart failure, and the mean follow-up period was 3.5 years. In addition, changes in exercise capacity based on CPX at 3–5 months from baseline were also examined. Results of this study showed that peak V̇O₂ at 3–5 months after CABG was significantly increased in active outpatient cardiac rehabilitation participants compared with non-active participants in this study. Multivariate Cox proportional analysis showed that active participation in outpatient cardiac rehabilitation was an independent prognostic predictor for MACE, rehospitalization for cardiac disease, and recurrent coronary events. At the end, this study showed the beneficial effects of outpatient cardiac rehabilitation on both exercise capacity and long-term prognosis in current patients after CABG for the first time.

In recent years, off-pump CABG has become mainstream and short hospital stays have made long-term in-hospital cardiac rehabilitation more difficult in Japan. Moreover, CABG for elderly patients has been positively selected, because the population is rapidly aging in Japan and surgical results have improved. Many of these elderly patients have limited activities of daily living (ADL) before surgery, because of comorbidities such as cerebrovascular disorders and motor organ disorders, and these elderly patients often do not improve exercise capacity sufficiently during hospitalization after surgery. Therefore, outpatient rehabilitation has become increasingly important in Japan, where the hospitalization period in acute hospitals is short and there are few rehabilitation hospitals that can perform in-hospital cardiac rehabilitation. However, the use of outpatient cardiac rehabilitation in patients with CVD, including patients after CABG, remains very low in Japan.¹⁵ This study by Origuchi et al, which has shown long-term prognostic effects of cardiac rehabilitation in patients after CABG, should be a milestone in the spread of outpatient cardiac rehabilitation in Japan.¹⁴ Ultimately, in order to improve long-term prognosis and exercise capacity in patients after CABG, we have to establish a system that enables cardiac rehabilitation to be continuously performed from the acute hospital to the local community as a therapeutic strategy for CABG (Figure) in Japan. It is important that the acute and rehabilitation hospitals cooperate so that the patient’s rehabilitation can transition smoothly from the acute phase to the recovery phase, and also to cooperate with the local community so that postoperative patients can continue their ADL and exercise safely in the community.

Figure.

Seamless implementation of cardiac rehabilitation. Building a system that performs cardiac rehabilitation seamlessly from acute hospital to the local community is an urgent issue. CV, cardiovascular.

Financial / Nonfinancial Disclosures

Hideo Izawa received grant support through his institution from Takeda, Shionogi, Otsuka, Pfizer, Teijin, and Daiichi-Sankyo and honoraria for lectures from Otsuka and Daiichi-Sankyo.

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