Prehabilitation in cardiac surgery: a state-of-the-art review.

Prehabilitation aims to improve postoperative outcomes by enhancing patients' physical and psychological resilience prior to surgery. It comprises three 'pillars'-exercise, nutritional and psychological components. Although well established in major non-cardiac surgery, prehabilitation has not been widely implemented in cardiac surgery.Candidates for cardiac surgery present unique challenges, including reduced cardiorespiratory fitness and high prevalence of frailty. Additionally, the dual care pathway differs markedly between elective outpatients and acutely admitted inpatients, with implications for timing, feasibility of the prehabilitation, as well as the components within it. Effective implementation is also dependent on behavioural considerations-wrapping the three pillars in a behavioural framework offers the best chance of an effective intervention.Despite biological plausibility and supportive signals from individual components, few high-quality, sufficiently powered trials have evaluated multimodal prehabilitation strategies in cardiac surgery. Large-scale pragmatic trials are beginning to be designed that will determine the clinical effectiveness and cost-effectiveness of prehabilitation in cardiac surgery. The outcomes of these will determine whether the potentially costly intervention of prehabilitation should be rolled out by healthcare providers.