Impact of functional status on survival after coronary artery bypass grafting in a veteran population

Homelessness and Race are Mortality Predictors in US Veterans Undergoing CABG

Coronary artery disease requiring surgical revascularization is prevalent in United States Veterans. We aimed to investigate preoperative predictors of 30-day mortality following coronary artery bypass grafting (CABG) in the Veteran population. The Veterans Affairs Surgical Quality Improvement (VASQIP) national database was queried for isolated CABG cases between 2008 and 2018. The primary outcome was 30-day mortality. A multivariable logistic regression was performed to assess for independent predictors of the primary outcome. A P-value of <0.05 was considered statistically significant. A total of 32,711 patients were included. The 30-day mortality rate was 1.37%. Multivariable analysis identified the following predictors of 30-day mortality: African-American race (OR 1.46, 95% CI 1.09-1.96); homelessness (OR 6.49, 95% CI 3.39-12.45); female sex (OR 2.15, 95% CI 1.08-4.30); preoperative myocardial infarction within 7 days (OR 1.49, 95% CI 1.06-2.10) or more than 7 days before CABG (OR 1.34, 95% CI 1.04-1.72); partially/fully dependent functional status (OR 1.44, 95% CI 1.07-1.93); chronic obstructive pulmonary disease (OR 1.54, 95% CI 1.24-1.92); mild (OR 1.48, 95% CI 1.04-2.11) and severe aortic stenosis (OR 2.06, 95% CI 1.37-3.09); moderate (OR 1.88, 95% CI 1.31-2.72), or severe (OR 2.99, 95% CI 1.71-5.22) mitral regurgitation; cardiomegaly (OR 1.73, 95% CI 1.35-2.22); NYHA Class III/IV heart failure (OR 2.05, 95% CI 1.10-3.83); and urgent/emergent operation (OR 1.42, 95% CI 1.08-1.87). The 30-day mortality rate in US Veterans undergoing isolated CABG between 2008 and 2018 was 1.37%. In addition to established clinical factors, African-American race and homelessness were independent demographic predictors of 30-day mortality.

Preoperative Short Physical Performance Battery as a predictor of prolonged hospitalization after coronary artery bypass grafting in older patients

Objective

The study aimed to evaluate the predictive value of the Short Physical Performance Battery (SPPB) and its three components for identifying the requirement for a prolonged hospitalization for coronary artery bypass grafting (CABG) in older patients.

Methods

This prospective, observational study included 425 older patients who consecutively underwent selective CABG surgery. All patients were assessed for the SPPB. We analysed the association of the postoperative length of hospital stay with the SPPB and three components. Receiver operating characteristic curve analysis was performed to determine the validity of the SPPB for predicting older patients with a prolonged hospitalization (>8 days).

Results

The SPPB and its three individual components were independent risk factors for a prolonged postoperative length of hospital stay. Only the SPPB summary score and the 4-m gait speed components showed good discriminative capabilities. An SPPB score cut-off of 9.5 provided the best accuracy for identifying a prolonged hospitalization. A poor physical performance (SPPB <10 score) was related to an increased risk of adverse cardiac and cerebrovascular events within 6 months after discharge.

Conclusions

This study provides evidence for clinical utility of the SPPB score for identifying older patients undergoing CABG who are at risk of prolonged hospitalization.

Frailty and pre-frailty in cardiac surgery: a systematic review and meta-analysis of 66,448 patients

BACKGROUND

The burden of frailty on cardiac surgical outcomes is incompletely understood. Here we perform a systematic review and meta-analysis of studies comparing frail versus pre-frail versus non-frail patients following cardiac surgery.

METHODS

We searched MEDLINE and EMBASE databases until July 2018 for studies comparing cardiac surgery outcomes in "frail", "pre-frail" and "non-frail" patients. Data was extracted in duplicate. Primary outcome was operative mortality.

RESULTS

There were 19 observational studies with 66,448 patients. Frail patients were more likely female (risk ratio [RR]1.7; 95%CI:1.5-1.9), older (mean difference: 2.4; 95%CI:1.3-3.5 years older) with greater comorbidities and higher STS-PROM. Frailty (RR2.35; 95%CI:1.57-3.51; p < 0.0001) and pre-frailty (RR2.03; 95%CI:1.52-2.70; p < 0.00001) were associated with increased operative mortality compared with non-frail patients. Frailty was also associated with greater risk of prolonged hospital stay (RR1.83; 95%CI:1.61-2.08; p < 0.0001) and intermediate care facility discharge (RR2.71; 95%CI:1.45-5.05; p = 0.002). Frail (Hazard Ratio [HR]3.27; 95%CI:1.93-5.55; p < 0.0001) and pre-frail patients (HR2.30; 95%CI:1.29-4.09; p = 0.005) had worse mid-term mortality (median follow-up 1 years [range 0.5-4 years]). After adjustment for baseline imbalances, frailty was still associated with greater operative mortality (odds ratio [OR]1.97; 95%CI:1.51-2.57; p < 0.00001), intermediate care facility discharge (OR4.61; 95%CI:2.78-7.66; p < 0.00001) and midterm mortality (HR1.37; 95%CI:1.03-1.83; p = 0.03).

CONCLUSION

In patients undergoing cardiac surgery, frailty and pre-frailty were associated with 2-fold and 1.5-fold greater adjusted operative mortality, respectively, greater adjusted perioperative complications and frailty was associated with almost 5-fold risk of non-home discharge. Burden of frailty and pre-frailty on cardiac surgical outcomes.

One-year mortality increases four-fold in frail patients undergoing cardiac surgery

OBJECTIVES

METHODS

A total of 604 patients aged ≥65 years undergoing non-acute cardiac surgery were included in this single-centre prospective observational study. We compared 1-year mortality and morbidity in frail versus non-frail patients. The Comprehensive Assessment of Frailty (CAF) score was used: This is a score of 1–35 determined via minor physical tests. A CAF score ≥11 indicates frailty.

RESULTS

The median age was 73 years and 79% were men. Twenty-five percent were deemed frail. Frail patients had four-fold, odds ratios 4.63, 95% confidence interval (CI) 2.21–9.69; P &lt; 0.001 increased 1-year mortality and increased risk of postoperative complications, i.e. surgical wound infections and prolonged hospital length of stay. A univariable Cox proportional hazards regression showed that an increased CAF score was a risk factor of mortality at any time after undergoing cardiac surgery (hazards ratios 1.11, 95% CI 1.07–1.14; P &lt; 0.001).

CONCLUSIONS

CAF score identified frail patients undergoing cardiac surgery and was a good predictor of 1-year mortality.

Clinical trial registration number

NCT02992587.

Preoperative Frailty Assessment and Outcomes at 6 Months or Later in Older Adults Undergoing Cardiac Surgical Procedures: A Systematic Review

BACKGROUND

Frailty assessment may inform surgical risk and prognosis not captured by conventional surgical risk scores.

PURPOSE

To evaluate the evidence for various frailty instruments used to predict mortality, functional status, or major adverse cardiovascular and cerebrovascular events (MACCEs) in older adults undergoing cardiac surgical procedures.

DATA SOURCES

MEDLINE and EMBASE (without language restrictions), from their inception to 2 May 2016.

STUDY SELECTION

Cohort studies evaluating the association between frailty and mortality or functional status at 6 months or later in patients aged 60 years or older undergoing major or minimally invasive cardiac surgical procedures.

DATA EXTRACTION

2 reviewers independently extracted study data and assessed study quality.

DATA SYNTHESIS

Mobility, disability, and nutrition were frequently assessed domains of frailty in both types of procedures. In patients undergoing major procedures (n = 18 388; 8 studies), 9 frailty instruments were evaluated. There was moderate-quality evidence to assess mobility or disability and very-low- to low-quality evidence for using a multicomponent instrument to predict mortality or MACCEs. No studies examined functional status. In patients undergoing minimally invasive procedures (n = 5177; 17 studies), 13 frailty instruments were evaluated. There was moderate- to high-quality evidence for assessing mobility to predict mortality or functional status. Several multicomponent instruments predicted mortality, functional status, or MACCEs, but the quality of evidence was low to moderate. Multicomponent instruments that measure different frailty domains seemed to outperform single-component ones.

LIMITATION

Heterogeneity of frailty assessment, limited generalizability of multicomponent frailty instruments, few validated frailty instruments, and potential publication bias.

CONCLUSION

Frailty status, assessed by mobility, disability, and nutritional status, may predict mortality at 6 months or later after major cardiac surgical procedures and functional decline after minimally invasive cardiac surgery.

PRIMARY FUNDING SOURCE

National Institute on Aging and National Heart, Lung, and Blood Institute.

Systematic review and meta-analysis of the association between frailty and outcome in surgical patients

INTRODUCTION

Frailty is becoming increasingly prevalent in the elderly population although a lack of consensus regarding a clinical definition hampers comparison of clinical studies. More elderly patients are being assessed for surgical intervention but the effect of frailty on surgical related outcomes is still not clear.

METHODS

A systematic literature search for studies prospectively reporting frailty and postoperative outcomes in patients undergoing surgical intervention was performed with data collated from a total of 12 studies. Random effects meta-analysis modelling was undertaken to estimate the association between frailty and mortality rates (in-hospital and one-year), length of hospital stay and the need for step-down care for further rehabilitation/nursing home placement.

RESULTS

Frailty was associated with a higher in-hospital mortality rate (pooled odds ratio [OR]: 2.77, 95% confidence interval [CI]: 1.62-4.73), a higher one-year mortality rate (pooled OR: 1.99, 95% CI: 1.49-2.66), a longer hospital stay (pooled mean difference: 1.05 days, 95% CI: 0.02-2.07 days) and a higher discharge rate to further rehabilitation/step-down care (pooled OR: 5.71, 95% CI: 3.41-9.55).

CONCLUSIONS

The presence of frailty in patients undergoing surgical intervention is associated with poorer outcomes with regard to mortality and return to independence. Further in-depth studies are required to identify factors that can be optimised to reduce the burden of frailty in surgical patients.

Fitness predicts long-term survival after a cardiovascular event: a prospective cohort study

OBJECTIVES

To identify the role of fitness, fitness change, body mass index and other factors in predicting long-term (>5 years) survival in patients with coronary heart disease.

DESIGN

Cohort study of patients with coronary heart disease recruited from 1 January 1993 to 31 December 2002, followed up to March 2011 (1 day to 18 years 3 months, mean 10.7 years).

SETTING

A community-based National Health Service (NHS) cardiac rehabilitation programme serving the Basingstoke and Alton area in Hampshire, UK.

PARTICIPANTS

An unselected cohort of NHS patients, 2167 men and 547 women aged 28-88 years, who attended the rehabilitation programme following acute myocardial infarction, an episode of angina or revascularisation, and had a baseline fitness test.

MAIN OUTCOME MEASURES

Cardiovascular mortality and all-cause mortality.

RESULTS

A high level of fitness (VO2≥22 mL/kg/min for men, VO2≥19 mL/kg/min for women) at completion of the programme was associated with decreased all-cause death, as was a prescription for statins or aspirin, and female gender. Increase in all-cause mortality was associated with higher age and ACE inhibitors prescription. Higher risk of cardiovascular mortality was associated with increasing age, prescriptions for ACE inhibitor, and diagnosis of myocardial infarction or angina as compared with the other diagnoses.

CONCLUSIONS

Prior fitness and fitness improvement are strong predictors of long-term survival in patients who have experienced a cardiac event or procedure. Some secondary prevention medications make a significant contribution to reducing all-cause mortality and cardiovascular mortality in these patients. This study supports public health messages promoting fitness for life.

In nonagenarians, acute kidney injury predicts in-hospital mortality, while heart failure predicts hospital length of stay

BACKGROUND/AIMS

The elderly constitute an increasing proportion of admitted patients worldwide. We investigate the determinants of hospital length of stay and outcomes in patients aged 90 years and older.

METHODS

We retrospectively analyzed all admitted patients aged >90 years from the general medical wards in a tertiary referral medical center between August 31, 2009 and August 31, 2012. Patients' clinical characteristics, admission diagnosis, concomitant illnesses at admission, and discharge diagnosis were collected. Each patient was followed until discharge or death. Multivariate logistic regression analysis was utilized to study factors associated with longer hospital length of stay (>7 days) and in-hospital mortality.

RESULTS

A total of 283 nonagenarian in-patients were recruited, with 118 (41.7%) hospitalized longer than one week. Nonagenarians admitted with pneumonia (p = 0.04) and those with lower Barthel Index (p = 0.012) were more likely to be hospitalized longer than one week. Multivariate logistic regression analysis revealed that patients with lower Barthel Index (odds ratio [OR] 0.98; p = 0.021) and those with heart failure (OR 3.05; p = 0.046) had hospital stays >7 days, while patients with lower Barthel Index (OR 0.93; p = 0.005), main admission nephrologic diagnosis (OR 4.83; p = 0.016) or acute kidney injury (OR 30.7; p = 0.007) had higher in-hospital mortality.

CONCLUSION

In nonagenarians, presence of heart failure at admission was associated with longer hospital length of stay, while acute kidney injury at admission predicted higher hospitalization mortality. Poorer functional status was associated with both prolonged admission and higher in-hospital mortality.