Aging Well in an Era of High-Tech Cardiovascular Care

Derivation of Patient-Defined Adverse Cardiovascular and Noncardiovascular Events Through a Modified Delphi Process

IMPORTANCE

There is little evidence to support patient-centered outcomes in patients with cardiovascular disease.

OBJECTIVE

To derive patient-defined adverse cardiovascular and noncardiovascular events (PACE) through a consensus-based process.

DESIGN, SETTING, AND PARTICIPANTS

This pan-Canadian, consensus-based, qualitative study used an iterative Delphi method to achieve consensus within a 35-member panel consisting of patients with cardiovascular diseases and their caregivers and clinicians. The process included 4 rounds of online questionnaires, followed by an in-person final consensus meeting. Data analysis was performed in September 2019.

MAIN OUTCOMES AND MEASURES

Defining PACE as a 5-item composite outcome.

RESULTS

Thirty-five potential panelists consented to participate, including 11 clinicians (8 men [73%]) and 24 patients and caregivers (13 men [54%]). Twenty-nine (83%), 28 (80%), 26 (74%), and 23 (66%) of the panelists participated in each of respective the online rounds. A shortlist of 11 patient-defined items was further refined at the in-person meeting, which 20 of the panelists attended. The PACE definition that was decided through the consensus process was a composite of severe stroke necessitating hospitalization for 14 days or longer or inpatient rehabilitation, ventilator dependence, new onset or worsening heart failure, nursing home admission, or new onset dialysis.

CONCLUSIONS AND RELEVANCE

This study defined PACE as a versatile, patient-centered outcome through a consensus process with input from patients, caregivers, and clinicians. Given the paucity of patient-centered outcomes in cardiovascular research, PACE may be considered as a potential outcome after methodological evaluation of its reliability.

Association of Frailty and Long-Term Survival in Patients Undergoing Coronary Artery Bypass Grafting

BACKGROUND

Frailty is increasing in prevalence and poses a formidable challenge for clinicians. The cardiac surgery literature consists primarily of small single-center studies with limited follow-up, and the epidemiological features of frailty remain to be elucidated in long-term follow-up.

METHODS AND RESULTS

We conducted a population-based, retrospective, cohort study in Ontario, Canada, between 2008 and 2015. Frailty was defined using the Johns Hopkins Adjusted Clinical Groups frailty indicator (a multidimensional instrument validated for research using administrative data). The primary outcome was mortality. Mortality rates were calculated using the Kaplan-Meier method. The hazard of death was assessed using a multivariable Cox proportional hazard model. Of 40 083 patients, 8803 (22%) were frail. At 4±2 years of follow-up, age- and sex-standardized mortality rate per 1000 person-years was higher in frail (33; 95% confidence interval, 29-36) compared with nonfrail (22; 95% confidence interval, 19-24) patients. Frailty was associated with an increased risk of long-term mortality (adjusted hazard ratio, 1.20; 95% confidence interval, 1.12-1.28) and greater differences in the survival of patients between 40 and 74 years of age than in those who were ≥85 years old.

CONCLUSIONS

Frailty was present in a large proportion of patients undergoing coronary artery bypass grafting and was independently associated with long-term mortality. The adjusted risk of frailty-related death was inversely proportional to age. Our findings highlight the need for more comprehensive preoperative risk stratification models to assist with optimal selection of operative candidates. In addition, we identified the <75 years age group as a potential target for comprehensive preoperative optimization programs, such as cardiac prehabilitation, nutritional augmentation, and psychosocial support.