Lakhasly

Cardiovascular diseases (CVDs) are a leading cause of global mortality, with significant healthcare costs projected to rise. Cardiac surgery, a crucial treatment for CVDs, is frequently associated with emotional distress (anxiety and depression) in patients, hindering recovery. Preoperative education, a key component of enhanced recovery pathways, aims to mitigate this distress by providing information on the perioperative process, improving psychological support, managing expectations, and promoting recovery. While some studies show preoperative education reduces anxiety, improves knowledge, and increases patient satisfaction, others report negligible effects on anxiety, depression, hospitalization length, and pain control. Previous reviews suffered from methodological limitations, lacking rigorous meta-analysis and consistent conclusions. This review, guided by PRISMA and Cochrane guidelines, aims to synthesize evidence on preoperative education's impact on perioperative outcomes (anxiety, depression, knowledge, pain, complications, hospitalization length, ICU stay, satisfaction, and HRQOL) in cardiac surgery patients using a meta-analysis of randomized controlled trials (RCTs) including published, unpublished, and ongoing studies in English, with participants aged 18 and older undergoing STS-defined cardiac procedures, excluding those with pre-existing psychological disorders or cognitive impairment. The review found that preoperative education significantly reduced anxiety, depression, ICU stay, and improved knowledge and satisfaction; however, further research is needed to assess its impact on pain, complications, hospitalization length, and HRQOL. Meta-analytic evidence supports consistent implementation of preoperative education in clinical settings and educational curricula.

Implications for practice

Undergoing cardiac surgery causes emotional distress sin adults which impedes surgical recovery.

Preoperative education significantly reduced patients' anxiety, depression, length of stay in the intensive care unit, and improved knowledge

and satisfaction. The effects of preoperative education pain intensity, pain interference with daily activities, postoperative complications, length of hospitalization, and health-related quality of life demands further research.

Meta-analytic evidence indicates the need for the consistent embedment of preoperative education in clinical settings and education curricula.

Introduction

Cardiovascular diseases (CVDs), disorders associated with the heart and blood vessels, consist of ischaemic heart diseases, heart failure, and peripheral arterial diseases. People with underlying CVDs may be asymptomatic or manifest chest discomfort, dizziness and palpita- tions. Globally, CVDs represent a leading cause of mortality, with an estimated 17.9 million deaths annually, corresponding to 31% of all deaths. With a disability burden of 366 million disability-adjusted life years, healthcare costs of CVDs are projected to rise to $818 billion by 2030.

Surgical interventions are integral medical treatments for patients with CVD. According to the Society of Thoracic Surgeons (STS). combinations of coronary artery bypass grafting (CABG), aortic valve replacement, mitral valve replacement, and mitral valve repair sur geries accounted for 79% of of major cardiac procedures performed. While cardiac surgeries increasingly common, they remain emotional experience for patients. Patients waiting for cardiac sur- geries often felt anxious and depressed (32% and 19%, respectively)." An operation on the dynamic and vital heart poses immense risks, which further intensifies such distress 2.10 Psychological stress impedes patients' surgical recovery by disrupting myocardial perfu- sion, triggering inflammatory responses" and contributing to desirable health behaviours of physical inactivity or poor treatment

compliance.12

Information provision is essential for patients undergoing cardiac surgery and those with high anxiety usually request for more infor mation regarding their surgery, and recovery. Preoperative educa- tion, defined as a fundamental element in the enhanced recovery after surgery pathway, seeks to provide patients with information for psychological support, setting health expectations, and promoting re- covery. It offers details on the perioperative process, a period encompassing preoperative, intraoperative, and postoperative ex- perience. During the education, health professionals might provide patients information on hospital admission procedures, preparatory tests, surgical techniques. postoperative care, and complications.14 The mode of delivery and materials used varies.

Preoperative education provides patients with a sense of what to expect for surgery, which reduces distress. Some studies have rec ognized beneficial effects of preoperative education on anxiety re duction." subjective health knowledge," and satisfaction. Conversely, other trials found negligible interventional effects on anx iety, depression, length of hospitalization, and pain control. 25 Therefore, these inconsistent findings need to be synthesized to

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SX. Ng et al.

draw reliable conclusions on the effectiveness of preoperative

education.

Existing reviews on this topic had methodological limitations and

lacked rigorous meta-analysis (Supplementary material online, File

$1). These reviews were mainly integrative or scoping reviews seek-

ing to identify the topic's literature size and were insufficient to rec- ommend clinical or policy change. Only one of three systematic reviews conducted a meta-analysis but included primary studies pub- lished before 2015, assessing merely four outcomes. With emerg ing trials, the evidence base has since grown and an update is imperative. Furthermore, all reviews presented diverse conclusions on the interventional effects. 27-29 Therefore. an updated systematic review using rigorous statistical methods of meta-analysis to address literature gaps, methodological limitations, and confront mixed results is crucial

This review aimed to synthesize the best available evidence evalu- ating the effectiveness of preoperative education in improving peri- operative outcomes [anxiety, depression, knowledge, pain intensity, pain interference with daily activities, postoperative complications. length of hospitalization, length of intensive care unit (ICU) stay, satis- faction, and health-related quality of life (HRQOL)] of patients under- going cardiac surgery.

Methods

The Preferred Reporting Items for Systematic Reviews and Meta-analysis (PRISMA) statement guided review development. Statistical analyses were performed according to Cochrane's Handbook for Systematic Reviews of Interventions guidelines. A review protocol was completed and submitted to the first author's institution on 11 December 2020 and it is available upon request, however, it was not registered

Eligibility criteria

We included randomized controlled trials (RCTs), published, unpub-

lished and ongoing, written in English, with no publication year restric tions. Participants who underwent a cardiac surgical procedure outlined by STS (Supplementary material online, File SZ), aged 18-years old and -years above were included. Participants with clinically diagnosed baseline psy chological disorders, cognitive impairment, and/or taking any psychotrop- ic medications, potentially influencing outcome measurements were excluded.

Studies were included if they provided preoperative educational inter ventions contextually relevant to cardiac surgeries (eg, surgical informa- tion). Interventions may vary in contents, duration, and delivery formats