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Original Investigation
June 22, 2022

Effectiveness and Safety of Early Initiation of Poststernotomy Cardiac Rehabilitation Exercise Training: The SCAR Randomized Clinical Trial

Author Affiliations
  • 1Warwick Clinical Trials Unit, Warwick Medical School, University of Warwick, Coventry, United Kingdom
  • 2Department of Cardiopulmonary Rehabilitation, Centre for Exercise & Health, University Hospital Coventry and Warwickshire National Health Service Trust, Coventry, United Kingdom
  • 3Warwick Medical School, University of Warwick, Coventry, United Kingdom
  • 4Centre for Sport, Exercise and Life Sciences, Research Institute for Health & Wellbeing, Coventry University, Coventry, United Kingdom
  • 5Department of Cardiology, University Hospital Coventry and Warwickshire National Health Service Trust, Coventry, United Kingdom
  • 6Department of Cardiothoracic Surgery, University Hospital Coventry and Warwickshire National Health Service Trust, Coventry, United Kingdom
JAMA Cardiol. 2022;7(8):817-824. doi:10.1001/jamacardio.2022.1651
Key Points

Question  Is starting cardiac rehabilitation exercise training 2 weeks after sternotomy as effective and safe as starting 6 weeks after sternotomy?

Findings  In this assessor-blind, noninferiority, randomized clinical trial of 158 cardiac surgery patients, starting cardiac rehabilitation exercise training 2 weeks after sternotomy was as effective, and likely as safe, as starting 6 weeks after sternotomy.

Meaning  By adopting a progressive individualized approach, patients who have median sternotomy can start cardiac rehabilitation exercise training up to 4 weeks earlier than current guidance and thus potentially complete their recovery sooner.

Abstract

Importance  Guidelines recommend that cardiac rehabilitation (CR) exercise training should not start until 6 weeks after sternotomy, although this is not evidence based. Limited data suggest that starting earlier is not detrimental, but clinical trials are needed.

Objective  To compare the effectiveness and safety of CR exercise training started either 2 weeks (early CR) or 6 weeks (usual-care CR) after sternotomy.

Design, Setting, and Participants  This was an assessor-blind, noninferiority, parallel-group, randomized clinical trial that conducted participant recruitment from June 12, 2017, to March 17, 2020. Participants were consecutive cardiac surgery sternotomy patients recruited from 2 outpatient National Health Service rehabilitation centers: University Hospital, Coventry, UK, and Hospital of St Cross, Rugby, UK.

Interventions  Participants were randomly assigned to 8 weeks of twice-weekly supervised CR exercise training starting either 2 weeks (early CR) or 6 weeks (usual-care CR) after sternotomy. Exercise training adhered to existing guidelines, including functional strength and cardiovascular components.

Main Outcomes and Measures  Outcomes were assessed at baseline (inpatient after surgery), after CR (10 or 14 weeks after sternotomy), and 12 months after randomization. The primary outcome was the change in 6-minute walk test distance from baseline to after CR. Secondary outcomes included safety, functional fitness, and quality of life.

Results  A total of 158 participants (mean [SD] age, 63 [11.5] years, 133 male patients [84.2%]) were randomly assigned to study groups; 118 patients (usual-care CR, 61 [51.7%]; early CR, 57 [48.3%]) were included in the primary analysis. Early CR was not inferior to usual-care CR (noninferiority margin, 35 m); the mean change in 6-minute walk distance from baseline to after CR was 28 m greater in the early CR group (95% CI, −11 to 66; P = .16). Mean differences for secondary outcomes were not statistically significant, indicating noninferiority of early CR. There were 46 vs 58 adverse events and 14 vs 18 serious adverse events in usual-care CR and early CR, respectively. There was no difference between the groups in the likelihood of participants having an adverse or serious adverse event.

Conclusions and Relevance  Starting exercise training from 2 weeks after sternotomy was as effective as starting 6 weeks after sternotomy for improving 6-minute walk distance. With appropriate precautions, clinicians and CR professionals can consider starting exercise training as early as 2 weeks after sternotomy.

Trial Registration  ClinicalTrials.gov Identifier: NCT03223558

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