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Banning LBD, van Munster BC, van Leeuwen BL, Trzpis M, Zeebregts CJ, Pol RA. Comparison of Various Functional Assessment Tools to Identify Older Patients Undergoing Aortic Aneurysm Repair at Risk for Postoperative Complications. Ann Vasc Surg 2024; 106:333-340. [PMID: 38815916 DOI: 10.1016/j.avsg.2024.02.032] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/28/2023] [Revised: 02/18/2024] [Accepted: 02/28/2024] [Indexed: 06/01/2024]
Abstract
BACKGROUND To estimate whether the benefits of aortic aneurysm repair will outweigh the risks, determining individual risks is essential. This single-center prospective cohort study aimed to compare the association of functional tools with postoperative complications in older patients undergoing aortic aneurysm repair. METHODS Ninety-eight patients (≥65 years) who underwent aortic aneurysm repair were included. Four functional tools were administered: the Montreal Cognitive Assessment (MoCA); the 4-Meter Walk Test (4-MWT); handgrip strength; and the Groningen Frailty Indicator (GFI). Primary outcome was the association between all tests and 30-day postoperative complications. RESULTS After adjusting for confounders, the odds ratio for MoCA was 1.39 (95% confidence interval [CI] 0.450; 3.157; P = 0.723), for 4-MWT 0.63 (95% CI 0.242; 1.650; P = 0.348), for GFI 1.82 (95% CI 0.783; 4.323, P = 0.162), and for weak handgrip strength 4.78 (95% CI 1.338; 17.096, P = 0.016). CONCLUSIONS Weak handgrip strength is significantly associated with the development of postoperative complications after aortic aneurysm repair. This study strengthens the idea that implementing a quick screening tool for risk assessment at the outpatient clinic, such as handgrip strength, identifies patients who may benefit from preoperative enhancement with help from, for example, Comprehensive Geriatric Assessment, eventually leading to better outcomes for this patient group.
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Affiliation(s)
- Louise B D Banning
- Divisions of Vascular Surgery, Department of Surgery, Transplantation Surgery and Oncologic Surgery, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands.
| | - Barbara C van Munster
- Division of Geriatric Medicine, University of Internal Medicine, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | - Barbara L van Leeuwen
- Divisions of Vascular Surgery, Department of Surgery, Transplantation Surgery and Oncologic Surgery, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | - Monika Trzpis
- Division of Geriatric Medicine, University of Internal Medicine, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | - Clark J Zeebregts
- Divisions of Vascular Surgery, Department of Surgery, Transplantation Surgery and Oncologic Surgery, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | - Robert A Pol
- Divisions of Vascular Surgery, Department of Surgery, Transplantation Surgery and Oncologic Surgery, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
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Campia U, Scimeca G. Frailty in Peripheral Artery Disease Patients Undergoing Revascularization: There Is Strength in Antithrombotic Therapy. J Am Coll Cardiol 2024; 84:812-814. [PMID: 39168567 DOI: 10.1016/j.jacc.2024.05.059] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/15/2024] [Accepted: 05/21/2024] [Indexed: 08/23/2024]
Affiliation(s)
- Umberto Campia
- Cardiovascular Division, Brigham and Women's Hospital, Boston, Massachusetts, USA; Thrombosis Research Group, Brigham and Women's Hospital, Boston, Massachusetts, USA.
| | - Giovanni Scimeca
- Thrombosis Research Group, Brigham and Women's Hospital, Boston, Massachusetts, USA
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Houghton JSM, Saratzis AN, Sayers RD, Haunton VJ. New Horizons in Peripheral Artery Disease. Age Ageing 2024; 53:afae114. [PMID: 38877714 PMCID: PMC11178507 DOI: 10.1093/ageing/afae114] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2023] [Indexed: 06/16/2024] Open
Abstract
Peripheral artery disease (PAD) is the lower limb manifestation of systemic atherosclerotic disease. PAD may initially present with symptoms of intermittent claudication, whilst chronic limb-threatening ischaemia (CLTI), the end stage of PAD, presents with rest pain and/or tissue loss. PAD is an age-related condition present in over 10% of those aged ≥65 in high-income countries. Guidelines regarding definition, diagnosis and staging of PAD and CLTI have been updated to reflect the changing patterns and presentations of disease given the increasing prevalence of diabetes. Recent research has changed guidelines on optimal medical therapy, with low-dose anticoagulant plus aspirin recommended in some patients. Recently published randomised trials highlight where bypass-first or endovascular-first approaches may be optimal in infra-inguinal disease. New techniques in endovascular surgery have increased minimally invasive options for ever more complex disease. Increasing recognition has been given to the complexity of patients with CLTI where a high prevalence of both frailty and cognitive impairment are present and a significant burden of multi-morbidity and polypharmacy. Despite advances in minimally invasive revascularisation techniques and reduction in amputation incidence, survival remains poor for many with CLTI. Shared decision-making is essential, and conservative management is often appropriate for older patients. There is emerging evidence of the benefit of specialist geriatric team input in the perioperative management of older patients undergoing surgery for CLTI. Recent UK guidelines now recommend screening for frailty, cognitive impairment and delirium in older vascular surgery patients as well as recommending all vascular surgery services have support and input from specialist geriatrics teams.
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Affiliation(s)
- John S M Houghton
- Department of Cardiovascular Sciences, University of Leicester, Leicester, UK
- Leicester Vascular Institute, University Hospitals of Leicester NHS Trust, Leicester, UK
- National Institute for Health Research Leicester Biomedical Research Centre—The Glenfield Hospital, Leicester, UK
| | - Athanasios N Saratzis
- Department of Cardiovascular Sciences, University of Leicester, Leicester, UK
- Leicester Vascular Institute, University Hospitals of Leicester NHS Trust, Leicester, UK
- National Institute for Health Research Leicester Biomedical Research Centre—The Glenfield Hospital, Leicester, UK
| | - Rob D Sayers
- Department of Cardiovascular Sciences, University of Leicester, Leicester, UK
- Leicester Vascular Institute, University Hospitals of Leicester NHS Trust, Leicester, UK
- National Institute for Health Research Leicester Biomedical Research Centre—The Glenfield Hospital, Leicester, UK
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Welsh SA, Pearson RC, Hussey K, Brittenden J, Orr DJ, Quinn T. A systematic review of frailty assessment tools used in vascular surgery research. J Vasc Surg 2023; 78:1567-1579.e14. [PMID: 37343731 DOI: 10.1016/j.jvs.2023.06.010] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2023] [Revised: 06/07/2023] [Accepted: 06/10/2023] [Indexed: 06/23/2023]
Abstract
OBJECTIVE Frailty is common in vascular patients and is recognized for its prognostic value. In the absence of consensus, a multitude of frailty assessment tools exist. This systematic review aimed to quantify the variety in these tools and describe their content and application to inform future research and clinical practice. METHODS Multiple cross-disciplinary electronic literature databases were searched from inception to August 2022. Studies describing frailty assessment in a vascular surgical population were eligible. Data extraction to a validated template included patient demographics, tool content, and analysis methods. A secondary systematic search for papers describing the psychometric properties of commonly used frailty tools was then performed. RESULTS Screening 5358 records identified 111 eligible studies, with an aggregate population of 5,418,236 patients. Forty-three differing frailty assessment tools were identified. One-third of these failed to assess frailty as a multidomain deficit and there was a reliance on assessing function and presence of comorbidity. Substantial methodological variability in data analysis and lack of methodological description was also identified. Published psychometric assessment was available for only 4 of the 10 most commonly used frailty tools. The Clinical Frailty Scale was the most studied and demonstrates good psychometric properties within a surgical population. CONCLUSIONS Substantial heterogeneity in frailty assessment is demonstrated, precluding meaningful comparisons of services and data pooling. A uniform approach to assessment is required to guide future frailty research. Based on the literature, we make the following recommendations: frailty should be considered a continuous construct and the reporting of frailty tools' application needs standardized. In the absence of consensus, the Clinical Frailty Scale is a validated tool with good psychometric properties that demonstrates usefulness in vascular surgery.
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Affiliation(s)
- Silje A Welsh
- College of Medical, Veterinary and Life Sciences, University of Glasgow, Glasgow, Scotland; Department of Vascular Surgery, Queen Elizabeth University Hospital, Glasgow, Scotland.
| | - Rebecca C Pearson
- Department of Medicine for the Elderly, Glasgow Royal Infirmary, Glasgow, Scotland
| | - Keith Hussey
- Department of Vascular Surgery, Queen Elizabeth University Hospital, Glasgow, Scotland
| | - Julie Brittenden
- College of Medical, Veterinary and Life Sciences, University of Glasgow, Glasgow, Scotland; Department of Vascular Surgery, Queen Elizabeth University Hospital, Glasgow, Scotland
| | - Douglas J Orr
- College of Medical, Veterinary and Life Sciences, University of Glasgow, Glasgow, Scotland; Department of Vascular Surgery, Queen Elizabeth University Hospital, Glasgow, Scotland
| | - Terry Quinn
- College of Medical, Veterinary and Life Sciences, University of Glasgow, Glasgow, Scotland
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DeRieux J, Obed D, Johnson A, Paisley MJ, Wang M, Casey KM. Frailty is Not Associated with Worse Outcomes following Lower Extremity Angiograms for Limb Ischemia in Nonagenarians. Ann Vasc Surg 2023; 96:261-267. [PMID: 37044241 DOI: 10.1016/j.avsg.2023.03.022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2023] [Revised: 02/25/2023] [Accepted: 03/19/2023] [Indexed: 04/14/2023]
Abstract
BACKGROUND Endovascular interventions are performed routinely with minimal risk in younger populations. The safety and efficacy of endovascular interventions in nonagenarians is under examined. We sought to examine the following (1) mortality and limb salvage rates in the nonagenarian population and (2) whether frailty was associated with outcomes following lower extremity (LE) interventions for both acute limb ischemia (ALI) and chronic limb threatening ischemia (CLTI). METHODS A retrospective review of patients ≥90 years who underwent a LE angiogram for ALI or CLTI over a 12-year period at a single institution was performed. Primary outcomes were 30-day and 12-month limb salvage and mortality rates. Patient demographics, 30-day complications, and 12-month target vessel reintervention (TVR) were reviewed. Frailty scores were calculated using the 11-factor modified frailty index (MFI-11). RESULTS From 2009 to 2021, 76 patients (36% male) with a mean age of 93 (range: 90-102) underwent endovascular procedures for ALI (n = 13) and CLTI (n = 63). 30-day amputation and mortality rates were 6% and 8%, respectively. Patient demographics, preoperative functional status, and TVR rates were not different between patients who had early amputation (≤30 days) and those who achieved limb salvage. Seventy-two patients (94%) had follow-up data at 30 days. There was an 8% mortality rate at 30 days. Of those alive at 30 days, 94% of patients had successful limb salvage. Fifty-eight patients had complete follow-up data at 12 months. Of the patients alive at 12-month follow-up (75%), the limb salvage rate was 98%. Patients with amputation at 30 days had a significantly higher mortality rate at 12 months compared to those who did not (83% vs. 19%; P < 0.01). Based on MFI-11 scoring, 35% of the population was considered frail (≥0.27). Frail patients did not have significantly different 30-day outcomes (limb salvage: 94% vs. 88%; mortality 8% vs. 9%, P = 0.41 and 0.94, respectively) or 12-month outcomes (limb salvage: 82% vs. 94%; mortality: 32% vs. 22%, P = 0.28 and 0.39, respectively). CONCLUSIONS Endovascular procedures can be done safely in nonagenarians with low mortality and amputation rates. Patients with early amputation are at significantly higher risk of death at 12 months. Frailty, as measured by a validated index, was not associated with early or late outcomes. When compared to immediate amputation, nonagenarian patients and their families should be counseled as to the benefit from a minimally invasive endovascular procedure.
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Affiliation(s)
- Jaclyn DeRieux
- Department of General Surgery, Santa Barbara Cottage Hospital, Santa Barbara, CA
| | - Dina Obed
- Department of General Surgery, Santa Barbara Cottage Hospital, Santa Barbara, CA
| | - Arianne Johnson
- Cottage Health Research Institute, Santa Barbara Cottage Hospital, Santa Barbara, CA
| | - Michael J Paisley
- Department of Vascular and Endovascular Surgery, Providence Health Sciences Oregon, Portland, OR
| | - Michelle Wang
- Department of General Surgery, Santa Barbara Cottage Hospital, Santa Barbara, CA
| | - Kevin M Casey
- Department of General Surgery, Santa Barbara Cottage Hospital, Santa Barbara, CA.
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Welch KG, Faria I, Browder SE, Drudi LM, McGinigle KL. Depression in Patients with Peripheral Artery Disease: An Underdiagnosis with Increased Mortality. Ann Vasc Surg 2023; 95:80-86. [PMID: 36948397 PMCID: PMC10866090 DOI: 10.1016/j.avsg.2023.03.002] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/04/2023] [Revised: 03/06/2023] [Accepted: 03/07/2023] [Indexed: 03/24/2023]
Abstract
BACKGROUND Among patients with peripheral artery disease (PAD), depression is diagnosed in 17-25% and negatively impacts wound healing, quality of life, and survival. We hypothesized that depression is underdiagnosed in patients with PAD. Additionally, given the associations between depression and mortality in PAD patients, there is an increased need to investigate the strength of this relationship. The present analysis includes 2 studies to address the following aims: (1) Investigation of the prevalence of concomitant PAD and depression in a cohort from the Southeastern United States, and (2) Examination of the association between depression and all-cause mortality in a cohort of Canadian patients with PAD. METHODS STUDY 1: From June-August 2022, the Patient Health Questionnaire Module 9 (PHQ-9) was administered to all patients seeking PAD-related care including medical, wound/podiatric, or vascular interventional/surgical treatment, in the University of North Carolina-Chapel Hill Vascular, Wound, and Podiatry clinics. The PHQ-9 assesses symptoms over 2 weeks and is scored 0-27, with higher scores indicating increasingly severe depression. Demographics, primary diagnosis, depression history, and antidepressant prescription were determined through chart review. We compared the proportion of positive depression screenings (PHQ-9 ≥ 5) to known depression. Among those treated for depression, the PHQ-9 score severity was evaluated. T-tests and χ2 tests were used to compare means and proportions. STUDY 2: From July 2015 to October 2016, the Geriatric Depression Scale Short Form was administered to adult patients with PAD undergoing revascularization. The Geriatric Depression Scale Short Form is a self-report measure of depression with a score >5 consistent with depression. The prevalence of depression was determined; primary outcome was all-cause mortality at 6 months. RESULTS STUDY 1: In 104 PAD patients (mean age 66.6 ± 11.3 years, 37% female), 37% of respondents scored ≥5 on the PHQ-9 survey, indicating at least mild depression. Only 18% of PAD patients had a history of depression, demonstrating a significant difference between the PHQ-9 findings and documented medical history. While depression was underdiagnosed in both men and women, men were more likely to have unrecognized depression (chi-squared statistic = 35.117, df = 1, P < 0.001). Among those with a history of depression, 74% had a current prescription for antidepressant medication, but 57% still had an elevated PHQ-9 score indicating possible undertreatment. STUDY 2: In 148 patients (mean age 70.3 ± 11.0 years, 39% female) the prevalence of screened depression was 28.4%, but only 3.3% had a documented history of depression suggesting significant underdiagnosis. Patients with depression were significantly more likely to die within 6 months of revascularization (9.5% vs. 0.9%; odds ratio 1.48, 95% confidence interval: 1.08 to 2.29). There was no association between depression and risk of length of stay, reintervention, or readmission. CONCLUSIONS Depression is underdiagnosed and undertreated among patients with PAD, which has grave consequences as it is associated with 1.5 times the odds of mortality within 6 months of revascularization. There is a critical need for more robust screenings and comprehensive mental health treatment for patients with concomitant depression and PAD.
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Affiliation(s)
- Katherine G Welch
- School of Medicine, University of North Carolina at Chapel Hill, Chapel Hill, NC
| | - Isabella Faria
- Department of Surgery, Beth Israel Deaconess Medical Center, Boston, MA
| | - Sydney E Browder
- Department of Epidemiology, Gillings School of Global Public Health, University of North Carolina at Chapel Hill, Chapel Hill, NC
| | - Laura M Drudi
- Division of Vascular Surgery, Centre Hospital de L'Université de Montréal, Montreal, Quebec, Canada
| | - Katharine L McGinigle
- Division of Vascular Surgery, School of Medicine, University of North Carolina at Chapel Hill, Chapel Hill, NC.
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McGinigle KL, Spangler EL, Ayyash K, Arya S, Settembrini AM, Thomas MM, Dell KE, Swiderski IJ, Davies MG, Setacci C, Urman RD, Howell SJ, Garg J, Ljungvist O, de Boer HD. A framework for perioperative care for lower extremity vascular bypasses: A Consensus Statement by the Enhanced Recovery after Surgery (ERAS®) Society and Society for Vascular Surgery. J Vasc Surg 2023; 77:1295-1315. [PMID: 36931611 DOI: 10.1016/j.jvs.2023.01.018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2022] [Revised: 12/30/2022] [Accepted: 01/03/2023] [Indexed: 03/17/2023]
Abstract
The Society for Vascular Surgery and the Enhanced Recovery After Surgery (ERAS) Society formally collaborated and elected an international, multi-disciplinary panel of experts to review the literature and provide evidence-based suggestions for coordinated perioperative care for patients undergoing infrainguinal bypass surgery for peripheral artery disease. Structured around the ERAS core elements, 26 suggestions were made and organized into preadmission, preoperative, intraoperative, and postoperative sections.
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Affiliation(s)
- Katharine L McGinigle
- Department of Surgery, School of Medicine, University of North Carolina at Chapel Hill, Chapel Hill, NC.
| | - Emily L Spangler
- Department of Surgery, School of Medicine, University of Alabama at Birmingham, Birmingham, AL
| | - Katie Ayyash
- Department of Perioperative Medicine (Merit), York and Scarborough Teaching Hospitals NHS Foundation Trust, York, United Kingdom
| | - Shipra Arya
- Department of Surgery, School of Medicine, Stanford University, Palo Alto, CA
| | | | - Merin M Thomas
- Lenox Hill Hospital, Northwell Health, New Hyde Park, NY
| | | | | | - Mark G Davies
- Department of Surgery, Joe R. & Teresa Lozano Long School of Medicine, University of Texas Health Sciences Center, San Antonio, TX
| | - Carlo Setacci
- Department of Surgery Surgery, University of Siena, Siena, Italy
| | - Richard D Urman
- Department of Anesthesiology, Perioperative and Pain Medicine, Brigham and Women's Hospital, Boston, MA
| | - Simon J Howell
- Leeds Institute of Medical Research at St. James's, University of Leeds, Leeds, United Kingdom
| | - Joy Garg
- Department of Vascular Surgery, Kaiser Permanente San Leandro, San Leandro, CA
| | - Olle Ljungvist
- Department of Surgery, Orebro University, Orebro, Sweden
| | - Hans D de Boer
- Department of Anesthesiology, Pain Medicine, and Procedure Sedation and Analgesia, Martini General Hospital Groningen, Groningen, the Netherlands
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Matsumoto T, Yamashita S, Yoshiga R, Guntani A, Ishida M, Mii S. Use of the 11-Item Modified Frailty Index to Determine Accurate Prognosis and Revascularization Strategy in Patients Undergoing Vascular Bypass Surgery for Intermittent Claudication. Ann Vasc Surg 2023; 91:201-209. [PMID: 36513159 DOI: 10.1016/j.avsg.2022.10.025] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2022] [Revised: 09/28/2022] [Accepted: 10/25/2022] [Indexed: 12/14/2022]
Abstract
BACKGROUND In cases of intermittent claudication (IC) where traditionally noninvasive management yields unsatisfactory results, revascularization strategy in IC patients is generally decided based on anatomical considerations and the availability of a saphenous vein graft. Life expectancy should also be considered. This study aimed to investigate the relationship between the 11-item modified frailty index (mFI-11) and the overall survival (OS) in patients with IC who underwent vascular bypass surgery to facilitate revascularization strategy selection. METHODS We reviewed the records of 144 consecutive patients (153 lower limbs) who underwent infrainguinal bypass for IC between 2011 and 2020. Patients were divided into 2 groups based on their mFI-11 score: high frailty (H), mFI score >0.3; and low frailty (L), mFI score ≤0.3. The OS was compared among the 2 groups. Rates of graft patency and freedom from major adverse limb event (ffMALE) were also determined and compared. RESULTS Five-year OS in the L and H groups was 92% and 55% (P < 0.001). Multivariate analysis showed that mFI, age, and end-stage renal disease were independent predictors of OS. Five-year rates of primary and secondary patency and ffMALE for vein grafts were 81%, 91%, and 94%, respectively; those for prosthetic grafts were 65%, 80%, and 84%, respectively; the differences were not significant. CONCLUSIONS The mFI-11 was a helpful tool in predicting OS for patients with IC who underwent vascular bypass surgery. Those with H should not undergo open revascularization; however, for IC patients who have either not responded to a regimen of exercise and medication, or have specifically requested a more aggressive approach, obtaining a good score in frailty assessment is useful in determining whether or not bypass surgery would be a viable option.
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Affiliation(s)
- Takuya Matsumoto
- Department of Vascular Surgery, Saiseikai Yahata General Hospital, Fukuoka, Japan
| | - Shou Yamashita
- Department of Vascular Surgery, Saiseikai Yahata General Hospital, Fukuoka, Japan
| | - Ryosuke Yoshiga
- Department of Vascular Surgery, Saiseikai Yahata General Hospital, Fukuoka, Japan
| | - Atsushi Guntani
- Department of Vascular Surgery, Saiseikai Yahata General Hospital, Fukuoka, Japan
| | - Masaru Ishida
- Department of Vascular Surgery, Steel Memorial Yawata Hospital, Fukuoka, Japan
| | - Shinsuke Mii
- Department of Vascular Surgery, Saiseikai Yahata General Hospital, Fukuoka, Japan.
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Yoshioka N, Tokuda T, Koyama A, Yamada T, Shimamura K, Nishikawa R, Morita Y, Morishima I. Two-year clinical outcomes and predictors of restenosis following the use of polymer-coated paclitaxel-eluting stents or drug-coated balloons in patients with femoropopliteal artery disease. Heart Vessels 2023; 38:429-437. [PMID: 36169709 DOI: 10.1007/s00380-022-02182-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/11/2022] [Accepted: 09/22/2022] [Indexed: 02/07/2023]
Abstract
We aimed to assess the clinical performance and risk factors for patency loss within 2 years following the use of polymer-coated paclitaxel-eluting stents (PC-PESs) and drug-coated balloons (DCBs) in patients with lower extremity artery disease. Multi-center registry data from 151 patients (65 and 86 treated with PC-PES and DCB, respectively) were retrospectively investigated. Two-year primary patency (PP) and clinically driven target lesion revascularization (CD-TLR) were evaluated using Kaplan-Meier analysis. Predictors of restenosis within 2 years of the procedures were analyzed using the random survival forest method. The consistent predictors of restenosis within 1 and 2 years were assessed and validated using Kaplan-Meier analysis. Two-year PP was 77.2 and 57.2% (log rank p = 0.047) and freedom from CD-TLR was 84.4 and 84.8% in the PC-PES and DCB groups, respectively (log rank p = 0.89). In the DCB group, most of the patients (n = 77, 89.5%) were treated with high-dose DCB. Consistent predictors of restenosis were lower vessel diameter and severity of Clinical Frailty Scale in the PC-PES group, and severity of peripheral artery calcification scoring system grade, severity of post dissection pattern, and smaller vessel diameter in the DCB group. The validation analysis revealed that patients with consistent predictors had significantly worse PP values than that of those without in the PC-PES (87.9% vs. 55.3%, log rank p = 0.003) and DCB groups (75.9% vs. 35.2%, log rank p = 0.001). The 2-year PP of DCBs was lower than that of PC-PESs. A smaller vessel diameter could predict restenosis in both devices. Vessel calcification and dissection should be considered when using DCB to ensure longer term patency.
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Affiliation(s)
- Naoki Yoshioka
- Department of Cardiology, Ogaki Municipal Hospital, 4-86 Minaminokawa-cho, Ogaki, Gifu, Japan.
| | - Takahiro Tokuda
- Department of Cardiology, Nagoya Heart Center, Nagoya, Japan
| | - Akio Koyama
- Department of Vascular Surgery, Ichinomiya Municipal Hospital, Ichinomiya, Japan
| | - Takehiro Yamada
- Department of Cardiology, Central Japan International Medical Center, Minokamo, Japan
| | | | - Ryusuke Nishikawa
- Department of Cardiovascular of Medicine, Kyoto University Graduate School of Medicine, Kyoto, Japan
| | - Yasuhiro Morita
- Department of Cardiology, Ogaki Municipal Hospital, 4-86 Minaminokawa-cho, Ogaki, Gifu, Japan
| | - Itsuro Morishima
- Department of Cardiology, Ogaki Municipal Hospital, 4-86 Minaminokawa-cho, Ogaki, Gifu, Japan
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Preoperative frailty risk in deep brain stimulation patients: Risk analysis index predicts Clavien-Dindo IV complications. Clin Neurol Neurosurg 2023; 226:107616. [PMID: 36773534 DOI: 10.1016/j.clineuro.2023.107616] [Citation(s) in RCA: 8] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2022] [Revised: 01/21/2023] [Accepted: 01/23/2023] [Indexed: 02/11/2023]
Abstract
OBJECTIVE Deep brain stimulation (DBS) improves patients' quality of life in multiple movement disorders and chronic neurodegenerative diseases. There are no published studies assessing frailty's impact on DBS outcomes. We evaluated frailty's impacts on DBS outcomes, comparing discriminative thresholds of the risk analysis index (RAI) to modified frailty index-5 (mFI-5) for predicting Clavien-Dindo complications (CDIV). METHODS Patients who underwent DBS between 2015 and 2019 in the ACS-NSQIP registry were included. We employed receiver operating characteristic (ROC) curve to examine the discriminative thresholds of RAI and mFI-5 and multivariable analyses for postoperative outcomes. Our primary outcome was CDIV, and secondary outcomes were discharge to higher-level care facility, unplanned reoperation within 30 days, in any hospital, for any procedure related to the index procedure, and extended length of stay. RESULTS A total of 3795 patients were included. In the ROC analysis for CDIV, RAI showed superior discriminative threshold (C-statistic = 0.70, 95% CI 0.61-0.80, <0.001) than mFI-5 (C-statistic = 0.60, 95% CI 0.49-0.70, P = 0.08). On multivariable analyses, frailty stratified by RAI, had independent associations with CDIV, i.e., pre-frail 2-fold increase OR 2.04 (95% CI: 1.94-2.14) p < 0.001, and frail 39% increase OR 1.39 (95% CI: 1.27-1.53), p < 0.001. CONCLUSION Frailty was an independent risk-factor for CDIV. The RAI had superior discriminative thresholds than mFI-5 in predicting CDIV after DBS. Our ability to identify frail patients prior to DBS presents a novel clinical opportunity for quality improvement strategies to target this specific patient population. RAI may be a useful primary frailty screening modality for potential DBS candidates.
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11
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Combined assessment of frailty and nutritional status can be a prognostic indicator after percutaneous coronary intervention. Heart Vessels 2023; 38:332-339. [PMID: 36171443 DOI: 10.1007/s00380-022-02176-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/03/2022] [Accepted: 09/14/2022] [Indexed: 02/07/2023]
Abstract
The cardiac prognosis of patients with frailty and malnutrition remains poorly investigated. This study aimed to investigate the impact of frailty and malnutrition on cardiac prognosis by combining the clinical frailty scale (CFS) and the geriatric nutritional risk index (GNRI) in patients who underwent percutaneous coronary intervention (PCI). In this study, 608 patients who underwent PCI for stable angina pectoris between January 2018 and December 2020 were included. CFS scores of ≥ 4 were defined as high CFS and patients with these scores were considered frail. GNRI scores of ≤ 98.0 were defined as low GNRI and patients with these scores were considered to have malnutrition. Patients were categorized into low-risk (n = 267, low CFS and high GNRI), intermediate-risk (n = 200, high CFS or low GNRI), and high-risk (n = 141, high CFS and low GNRI) groups. Major adverse clinical events (MACEs), including all-cause death, nonfatal myocardial infarction, revascularization, hospitalization for heart failure, and stroke, were assessed. The median follow-up period was 529 days. During the follow-up, MACEs were found in 135 patients. The high-risk group were older (77.0 ± 9.2 vs 71.4 ± 10.7 vs 65.0 ± 10.1 years, p < 0.001), had higher prevalence rates of chronic kidney disease [61.7% (87/141) vs 37.5% (75/200) vs 16.9% (45/267); p < 0.001] and heart failure [47.5% (67/141) vs 22.5% (45/200) vs 12.4% (33/267), p < 0.001], and had higher C-reactive protein levels (1.64 ± 2.66 vs 1.00 ± 2.02 vs 0.34 ± 0.90 mg/dL; p < 0.001) than the intermediate-risk and low-risk groups. The high-risk group [hazard ratio (HR), 4.39; 95% confidence interval (CI), 2.87-6.72; p < 0.001] was an independent predictor of MACEs. In conclusion, patients with both frailty and malnutrition had a higher risk of MACEs after PCI than patients with frailty or malnutrition. Post-PCI patients should be evaluated for combined frailty and malnutrition.
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12
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Finazzi A, Bruni AA, Nistri S, Bellelli G. Asymptomatic Aortic Stenosis in an Older Patient: How the Geriatric Approach Can Make a Difference. Diagnostics (Basel) 2023; 13:909. [PMID: 36900053 PMCID: PMC10001207 DOI: 10.3390/diagnostics13050909] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/31/2022] [Revised: 02/09/2023] [Accepted: 02/21/2023] [Indexed: 03/05/2023] Open
Abstract
We present a case report of an older patient with aortic stenosis who was managed before and after transcatheter aortic valve implantation by a team of cardiologists but without the support of a geriatrician. We first describe the patient's post-interventional complications from a geriatric perspective and afterwards, discuss the unique approach that the geriatrician would have provided. This case report was written by a group of geriatricians working in an acute hospital, along with a clinical cardiologist who is an expert in aortic stenosis. We discuss the implications for modifying conventional practice in tandem with existing literature.
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Affiliation(s)
- Alberto Finazzi
- School of Medicine and Surgery, University of Milano-Bicocca, 20900 Monza, Monza-Brianza, Italy
| | | | - Stefano Nistri
- Cardiology Service C.M.S.R. Veneto Medica, Altavilla Vicentina, 36077 Vicenza, Italy
| | - Giuseppe Bellelli
- School of Medicine and Surgery, University of Milano-Bicocca, 20900 Monza, Monza-Brianza, Italy
- Acute Geriatric Unit, S. Gerardo Hospital, 20900 Monza, Monza-Brianza, Italy
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13
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Fernando ME, Blanchette V, Mishra R, Zulbaran-Rojas A, Rowe V, Mills JL, Armstrong DG, Najafi B. Frailty in People with Chronic Limb Threatening Ischemia and Diabetes-Related Foot Ulcers: A Systematic Review. Ann Vasc Surg 2023; 89:322-337. [PMID: 36332876 DOI: 10.1016/j.avsg.2022.09.057] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2022] [Revised: 09/13/2022] [Accepted: 09/22/2022] [Indexed: 11/06/2022]
Abstract
BACKGROUND Frailty represents a state of multisystem impairment that may adversely impact people presenting with chronic limb-threatening ischemia (CLTI) and diabetes-related foot ulcers (DFUs). The aim of this systematic review was to explore the association between frailty and outcomes from CLTI and DFUs. METHODS We performed a systematic literature search of electronic databases to find studies using a validated measure of frailty in individuals with CLTI and/or DFUs. The primary outcomes were the impact of frailty on the severity of initial clinical presentation and unfavorable follow-up outcomes including readmissions, major limb amputation, cardiovascular events, revascularization, and wound healing. RESULTS Ten cohort studies were included. Two studies had a low risk of bias, 1 was unable to be assessed, 5 had moderate risk of bias, and 2 high risk of bias. The prevalence of frailty in people presenting with CLTI ranged from 27% to 88% and was 71% in people with DFUs. The presence of frailty in both people with CLTI and DFUs was associated with substantially increased severity at presentation (severity of ischemia and tissue loss) and poorer outcomes at follow-up (risk of readmission, limb amputation, and all-cause mortality). CONCLUSIONS The presence of frailty in both people with CLTI and DFUs is likely associated with substantially higher complexity at presentation followed by a greater risk for readmission, amputation, and death during follow-up. Heterogeneity in the tools used to screen for frailty, poor definition of frailty, and unclear evaluation of exposure and outcomes limit further interpretation of findings.
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Affiliation(s)
- Malindu E Fernando
- Interdisciplinary Consortium on Advanced Motion Performance (iCAMP), Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, TX; Southwestern Academic Limb Salvage Alliance (SALSA), Department of Surgery, Keck School of Medicine of University of Southern California, Los Angeles, CA; Ulcer and wound Healing consortium (UHEAL), Queensland Research Centre for Peripheral Vascular Disease, College of Medicine and Dentistry, James Cook University, Townsville, Queensland, Australia; Faculty of Health and Medicine, School of Health Sciences, University of Newcastle, Australia
| | - Virginie Blanchette
- Southwestern Academic Limb Salvage Alliance (SALSA), Department of Surgery, Keck School of Medicine of University of Southern California, Los Angeles, CA; Department of Human Kinetics and Podiatric Medicine, Université du Québec à Trois-Rivières, Trois-Rivières, Québec, Canada; VITAM-Centre de recherche en Santé durable, Québec, Québec, Canada
| | - Ramkinker Mishra
- Interdisciplinary Consortium on Advanced Motion Performance (iCAMP), Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, TX; Division of Vascular Surgery and Endovascular Therapy, Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, TX
| | - Alejandro Zulbaran-Rojas
- Interdisciplinary Consortium on Advanced Motion Performance (iCAMP), Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, TX; Division of Vascular Surgery and Endovascular Therapy, Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, TX
| | - Vincent Rowe
- Southwestern Academic Limb Salvage Alliance (SALSA), Department of Surgery, Keck School of Medicine of University of Southern California, Los Angeles, CA
| | - Joseph L Mills
- Division of Vascular Surgery and Endovascular Therapy, Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, TX
| | - David G Armstrong
- Southwestern Academic Limb Salvage Alliance (SALSA), Department of Surgery, Keck School of Medicine of University of Southern California, Los Angeles, CA
| | - Bijan Najafi
- Interdisciplinary Consortium on Advanced Motion Performance (iCAMP), Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, TX; Division of Vascular Surgery and Endovascular Therapy, Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, TX.
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14
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Nishikawa K, Ebisawa S, Miura T, Kato T, Yusuke K, Abe N, Yokota D, Yanagisawa T, Senda K, Wakabayashi T, Oyama Y, Karube K, Itagaki T, Yui H, Maruyama S, Nagae A, Sakai T, Okina Y, Nakazawa S, Tsukada S, Saigusa T, Okada A, Motoki H, Kagoshima M, Kuwahara K. Impact of Frailty and Age on Clinical Outcomes in Patients Who Underwent Endovascular Therapy. J Endovasc Ther 2022; 29:845-854. [PMID: 34969317 DOI: 10.1177/15266028211067729] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
PURPOSE Information on the relationship between frailty and the outcome of endovascular therapy (EVT) in elderly patients with lower extremity peripheral artery disease (PAD) is scarce. This study aimed to reveal the impact of frailty on the prognosis of super-elderly patients who underwent EVT. MATERIALS AND METHODS From August 2015 to August 2016, 335 consecutive patients who underwent EVT were enrolled in the I-PAD registry from 7 institutes in Nagano prefecture. Among them, we categorized 323 patients into 4 groups according to age and the presence or absence of frailty as follows: elderly with frailty (age ≥ 75, Clinical Frailty Scale [CFS] ≥ 5), elderly without frailty (age ≥ 75, CFS ≤ 4), young with frailty (age < 75, CFS ≥ 5), and young without frailty (age < 75, CFS ≤ 4); we analyzed them accordingly. The primary endpoints were major adverse cardiovascular and limb events (MACLE), defined as a composite of cardiovascular death, myocardial infarction, stroke, admission for heart failure, major amputation, and revascularization. The secondary endpoint was cardiovascular death. RESULTS The median follow-up period was 2.7 years. In the elderly with frailty, elderly without frailty, young with frailty, and young without frailty groups, the freedom rates from MACLE were 34.9%, 55.7%, 35.4%, and 63.0%, respectively (p<0.001) and from all-cause death were 43.5%, 73.4%, 50.7%, and 90.9%, respectively (p<0.001). The freedom rates from MACLE were significantly higher among elderly patients with frailty than among young patients without frailty (55.7% vs 35.4%, p=0.01). In multivariate analysis, frailty was independently associated with MACLE incidence. CONCLUSION Frailty as defined by CFS might be a predictor of MACLE incidence in patients with PAD who underwent EVT. By considering treatment indications for patients with PAD by focusing on frailty rather than age, we may examine whether EVT policies are appropriate and manage patient and caregiver expectations for potential improvement in functional outcomes. Further studies are expected to investigate whether changes in frailty after EVT change prognosis.
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Affiliation(s)
- Ken Nishikawa
- Department of Cardiovascular Medicine, Joetsu General Hospital, Niigata, Japan
| | - Soichiro Ebisawa
- Department of Cardiovascular Medicine, Shinshu University School of Medicine, Nagano, Japan
| | - Takashi Miura
- Department of Cardiovascular Medicine, Nagano Municipal Hospital, Nagano, Japan
| | - Tamon Kato
- Department of Cardiovascular Medicine, Shinshu University School of Medicine, Nagano, Japan
| | - Kanzaki Yusuke
- Department of Cardiovascular Medicine, Shinonoi General Hospital, Nagano, Japan
| | - Naoyuki Abe
- Department of Cardiovascular Medicine, Japanese Red Cross Society Nagano Hospital, Nagano, Japan
| | - Daisuke Yokota
- Department of Cardiovascular Medicine, Iida Hospital, Nagano, Japan
| | - Takashi Yanagisawa
- Department of Cardiovascular Medicine, Saku Central Hospital, Nagano, Japan
| | - Keisuke Senda
- Department of Cardiovascular Medicine, Aizawa Hospital, Nagano, Japan
| | | | - Yushi Oyama
- Department of Cardiovascular Medicine, Japanese Red Cross Society Suwa Hospital, Nagano, Japan
| | - Kenichi Karube
- Department of Cardiovascular Medicine, Okaya City Hospital, Nagano, Japan
| | - Tadashi Itagaki
- Department of Cardiovascular Medicine, Ina Central Hospital, Nagano, Japan
| | - Hisanori Yui
- Department of Cardiovascular Medicine, Shinshu University School of Medicine, Nagano, Japan
| | - Shusaku Maruyama
- Department of Cardiovascular Medicine, Shinshu University School of Medicine, Nagano, Japan
| | - Ayumu Nagae
- Department of Cardiovascular Medicine, Shinshu University School of Medicine, Nagano, Japan
| | - Takahiro Sakai
- Department of Cardiovascular Medicine, Shinshu University School of Medicine, Nagano, Japan
| | - Yoshiteru Okina
- Department of Cardiovascular Medicine, Joetsu General Hospital, Niigata, Japan
| | - Shun Nakazawa
- Department of Cardiovascular Medicine, Joetsu General Hospital, Niigata, Japan
| | - Shunichi Tsukada
- Department of Cardiovascular Medicine, Joetsu General Hospital, Niigata, Japan
| | - Tatsuya Saigusa
- Department of Cardiovascular Medicine, Shinshu University School of Medicine, Nagano, Japan
| | - Ayako Okada
- Department of Cardiovascular Medicine, Shinshu University School of Medicine, Nagano, Japan
| | - Hirohiko Motoki
- Department of Cardiovascular Medicine, Shinshu University School of Medicine, Nagano, Japan
| | - Mitsuru Kagoshima
- Department of Cardiovascular Medicine, Joetsu General Hospital, Niigata, Japan
| | - Koichiro Kuwahara
- Department of Cardiovascular Medicine, Shinshu University School of Medicine, Nagano, Japan
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Kotov A, Blasche DA, Peters F, Pospiech P, Rother U, Stavroulakis K, Remig J, Schmidt-Lauber C, Zeller T, Görtz H, Teßarek J, Behrendt CA. The Impact of Chronic Kidney Disease on Mid-Term Outcomes after Revascularisation of Peripheral Arterial Occlusive Disease: Results from a Prospective Cohort Study. J Clin Med 2022; 11:4750. [PMID: 36012989 PMCID: PMC9409847 DOI: 10.3390/jcm11164750] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2022] [Revised: 08/09/2022] [Accepted: 08/12/2022] [Indexed: 11/16/2022] Open
Abstract
OBJECTIVE The current study aimed to determine the relationship between chronic kidney disease (CKD) and major 12-month outcomes for patients with in-hospital treatment for symptomatic peripheral arterial occlusive disease (PAOD). METHODS An analysis of the prospective longitudinal multicentric cohort study with 12-month follow-up was conducted including patients who underwent endovascular or open surgery for symptomatic PAOD at 35 German vascular centres (initial study protocol: NCT03098290). Severity of CKD was grouped into four stages combining information about the estimated glomerular filtration rate (eGFR) at baseline and dialysis dependency. Outcomes included overall mortality as well as the two composite endpoints of amputation or death, and of major cardiovascular events (MACE). 12-month incidences and adjusted hazard ratios were estimated using the Kaplan-Meier function and Cox proportional hazard models. RESULTS A total of 4354 patients (32% female, 69 years mean age, 68% intermittent claudication, 69% percutaneous endovascular revascularisation) were included and followed for 244 days in median. Thereof, 22% had any CKD and 5% had end stage kidney disease (ESKD) at baseline. The 12-month overall mortality rate was 3.6% (95% CI 2.3-4.9) with 96 events in the entire cohort: 147 were amputated or died (5.3%, 95% CI 5.2-5.3), and 277 had a MACE (9.5%, 95% CI 9.4-9.5). When compared with patients without kidney disease, ESKD was significantly associated with overall mortality (HR 1.9; 95% CI 1.1-3.5), amputation or death (HR 2.4; 95% CI 1.4-4.1), and MACE (HR 2.0; 95% CI 1.3-3.2). CONCLUSIONS In the current study on mid-term outcomes after invasive revascularisation for symptomatic PAOD, one out of five patients suffered from any CKD while those few with ESKD had twice the odds of death, of amputation or death, and of major adverse cardiovascular events after twelve months. These results emphasise that concomitant CKD and its impact on outcomes should be considered by severity while mild and moderate grades should not lead to ineffectual treatment strategies.
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Affiliation(s)
- Artur Kotov
- Research Group GermanVasc, University Medical Centre Hamburg-Eppendorf, 20246 Hamburg, Germany
| | - Deven A. Blasche
- Research Group GermanVasc, University Medical Centre Hamburg-Eppendorf, 20246 Hamburg, Germany
| | - Frederik Peters
- Research Group GermanVasc, University Medical Centre Hamburg-Eppendorf, 20246 Hamburg, Germany
| | - Philip Pospiech
- Research Group GermanVasc, University Medical Centre Hamburg-Eppendorf, 20246 Hamburg, Germany
| | - Ulrich Rother
- Department of Vascular Surgery, University Medical Centre Erlangen, 91054 Erlangen, Germany
- Commission on Peripheral Artery Disease and Diabetic Foot Syndrome, German Society for Vascular Surgery and Vascular Medicine, 10115 Berlin, Germany
| | - Konstantinos Stavroulakis
- Commission on Peripheral Artery Disease and Diabetic Foot Syndrome, German Society for Vascular Surgery and Vascular Medicine, 10115 Berlin, Germany
- Department of Vascular Surgery, Ludwig Maximilians University Hospital, 80539 Munich, Germany
| | - Jürgen Remig
- Bonn Community Hospital, Haus St. Petrus, 53113 Bonn, Germany
| | - Christian Schmidt-Lauber
- III. Department of Medicine, University Medical Centre Hamburg-Eppendorf, 20246 Hamburg, Germany
| | - Thomas Zeller
- Clinic for Cardiology and Angiology II, University Heart Center Freiburg-Bad Krozingen, 79189 Bad Krozingen, Germany
| | - Hartmut Görtz
- Commission on Peripheral Artery Disease and Diabetic Foot Syndrome, German Society for Vascular Surgery and Vascular Medicine, 10115 Berlin, Germany
- St. Boniface Hospital Lingen, 49808 Lingen, Germany
| | - Jörg Teßarek
- St. Boniface Hospital Lingen, 49808 Lingen, Germany
| | - Christian-Alexander Behrendt
- Research Group GermanVasc, University Medical Centre Hamburg-Eppendorf, 20246 Hamburg, Germany
- Commission on Peripheral Artery Disease and Diabetic Foot Syndrome, German Society for Vascular Surgery and Vascular Medicine, 10115 Berlin, Germany
- Brandenburg Medical School Theodor Fontane, 16816 Neuruppin, Germany
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16
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Impact of frailty on all-cause mortality or major amputation in patients with lower extremity peripheral artery disease: A meta-analysis. Ageing Res Rev 2022; 79:101656. [PMID: 35654353 DOI: 10.1016/j.arr.2022.101656] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/06/2022] [Revised: 04/15/2022] [Accepted: 05/27/2022] [Indexed: 12/19/2022]
Abstract
BACKGROUND Frailty has been increasingly identified as a risk factor of adverse outcomes in vascular disease. However, its impact on the survival and amputation in patients with lower extremity peripheral artery disease (PAD) remains controversial. This meta-analysis aimed to examine the value of frailty in predicting all-cause mortality or major amputation in patients with lower extremity PAD. METHODS PubMed, Embase, Web of Sciences, and Scopus databases (up to April 7, 2022) were comprehensively searched to identify relevant studies that investigated the association between frailty and all-cause mortality or major amputation in patients with lower extremity PAD. The impact of frailty on adverse outcomes was summarized by pooling the fully adjusted hazard ratio (HR) with 95% confidence intervals (CI) using a random effect (DerSimonian-Laird) model. RESULTS Seven studies reporting on eight articles that involved 122,892 patients were included. The prevalence of frailty ranged from 42% to 80% based on the frailty tool used. Meta-analysis showed that frailty was associated with an increased risk of 30-day all-cause mortality (HR 2.11; 95% CI 1.41-3.15; I2 =47.6%, p = 0.148, Tau-squared=0.058) and long-term all-cause mortality (HR 1.86; 95% CI 1.25-2.76; I2 =76.1%, p = 0.002, Tau-squared=0.118). However, no clear association was observed between frailty and major amputation (HR 1.07; 95% CI 0.83-1.36; I2 =23.0%, p = 0.273, Tau-squared=0.019). CONCLUSION Frailty independently predicts short and long-term all-cause mortality but not major amputation in patients with lower extremity PAD. Frailty status may play an important role in risk stratification of lower extremity PAD.
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Ferreira J, Carneiro A, Vila I, Cunha C, Silva C, Longatto-Filho A, Mesquita A, Cotter J, Mansilha A, Correia-Neves M, Cunha P. Association of skeletal muscle and cardiovascular risk factors in patients with lower extremity arterial disease. Ann Vasc Surg 2021; 80:223-234. [PMID: 34688875 DOI: 10.1016/j.avsg.2021.08.037] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2021] [Revised: 07/31/2021] [Accepted: 08/05/2021] [Indexed: 11/01/2022]
Abstract
BACKGROUND Sarcopenia is defined as low muscle mass, with low muscle strength or low physical performance. The skeletal muscle mass (or density) and strength are inversely associated with cardiovascular risk factors. We aim to determine the relationship between skeletal muscle characteristics (strength, mass, area), and cardiovascular risk factors in a population with lower extremity artery disease (LEAD) METHODS: : An observational, prospective study including patients with LEAD was conducted from January 2018 to December 2020. The cardiovascular risk factors and anthropometric measurements were prospectively registered. The skeletal muscle characteristics (area, density/mass and strength) were analysed. The skeletal muscle area and density were quantified with a CT scan. The strength was determined with a Jamar® hydraulic hand dynamometer. RESULTS 96 patients with LEAD with 67.70± 10.11 years-old were enrolled in the study. The most prevalent cardiovascular risk factor was hypertension, followed by dyslipidemia and diabetes. Patients with diabetes had a lower handgrip strength and skeletal muscle density, when compared with patients without diabetes (strength: 19.67± 9.98 kgf versus 26.79 ± 11.80 kgf, p=0.002 and skeletal muscle density: 10.58 ± 17.61 HU versus 18.17 ± 15.33 HU, p=0.032). There was a trend for the association between the presence of cardiovascular risk factors (hypertension and dyslipidemia) and a decrease in skeletal muscle density and strength (density: hypertension: 13.46 ± 16.74 HU versus 20.38 ± 11.63 HU p=0.055; dyslipidemia: 13.57 ± 17.16 HU versus 17.74 ± 13.00 HU p=0.315; strength- hypertension: 22.55 ± 10.08 kgf versus 27.58 ± 15.11 p= 0.073; dyslipidemia: 22.80 ± 10.52 kgf versus 25.28 ± 13.14 kgf p=0.315). Interestingly, we found that smokers had a favorable skeletal muscle characteristic, which could be explained by the higher prevalence of diabetes in non-smokers. CONCLUSIONS The indicators of skeletal muscle dysfunction (strength and density) are associated to the presence of diabetes in patients with LEAD. Therapeutic strategies to improve the skeletal muscle characteristics could have a role in improving LEAD risk factors, particularly diabetes.
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Affiliation(s)
- J Ferreira
- Vascular Surgery Department- Hospital da Senhora da Oliveira, Guimarães, Portugal; Life and Health Science Research Institute (ICVS), School of Medicine, University of Minho, Braga, Portugal; ICVS/3B's-PT Government Associate Laboratory, Braga/Guimarães, Portugal.
| | - A Carneiro
- Radiology Department- ULSAM, Viana do Castelo, Portugal
| | - I Vila
- Life and Health Science Research Institute (ICVS), School of Medicine, University of Minho, Braga, Portugal; ICVS/3B's-PT Government Associate Laboratory, Braga/Guimarães, Portugal; Medicine Department- Hospital da Senhora da Oliveira, Guimarães, Portugal; Center for the Research and Treatment of Arterial Hypertension and Cardiovascular Risk, Internal Medicine Department- Hospital da Senhora da Oliveira, Guimarães, Portugal
| | - C Cunha
- Life and Health Science Research Institute (ICVS), School of Medicine, University of Minho, Braga, Portugal; ICVS/3B's-PT Government Associate Laboratory, Braga/Guimarães, Portugal; Medicine Department- Hospital da Senhora da Oliveira, Guimarães, Portugal; Center for the Research and Treatment of Arterial Hypertension and Cardiovascular Risk, Internal Medicine Department- Hospital da Senhora da Oliveira, Guimarães, Portugal
| | - C Silva
- Life and Health Science Research Institute (ICVS), School of Medicine, University of Minho, Braga, Portugal; ICVS/3B's-PT Government Associate Laboratory, Braga/Guimarães, Portugal; Medicine Department- Hospital da Senhora da Oliveira, Guimarães, Portugal; Center for the Research and Treatment of Arterial Hypertension and Cardiovascular Risk, Internal Medicine Department- Hospital da Senhora da Oliveira, Guimarães, Portugal
| | - A Longatto-Filho
- Life and Health Science Research Institute (ICVS), School of Medicine, University of Minho, Braga, Portugal; ICVS/3B's-PT Government Associate Laboratory, Braga/Guimarães, Portugal; Center for the Research and Treatment of Arterial Hypertension and Cardiovascular Risk, Internal Medicine Department- Hospital da Senhora da Oliveira, Guimarães, Portugal; Department of Pathology (LIM-14), University of São Paulo School of Medicine, São Paulo, Brazil; Molecular Oncology Research Center, Barretos Cancer Hospital, Barretos, São Paulo, Brazil
| | - A Mesquita
- Vascular Surgery Department- Hospital da Senhora da Oliveira, Guimarães, Portugal
| | - J Cotter
- Life and Health Science Research Institute (ICVS), School of Medicine, University of Minho, Braga, Portugal; ICVS/3B's-PT Government Associate Laboratory, Braga/Guimarães, Portugal; Medicine Department- Hospital da Senhora da Oliveira, Guimarães, Portugal; Center for the Research and Treatment of Arterial Hypertension and Cardiovascular Risk, Internal Medicine Department- Hospital da Senhora da Oliveira, Guimarães, Portugal
| | - A Mansilha
- Faculty of Medicine, University of Porto, Porto, Portugal; Vascular Surgery Department Hospital de São João, Porto, Portugal
| | - M Correia-Neves
- Life and Health Science Research Institute (ICVS), School of Medicine, University of Minho, Braga, Portugal; ICVS/3B's-PT Government Associate Laboratory, Braga/Guimarães, Portugal
| | - P Cunha
- Life and Health Science Research Institute (ICVS), School of Medicine, University of Minho, Braga, Portugal; ICVS/3B's-PT Government Associate Laboratory, Braga/Guimarães, Portugal; Medicine Department- Hospital da Senhora da Oliveira, Guimarães, Portugal; Center for the Research and Treatment of Arterial Hypertension and Cardiovascular Risk, Internal Medicine Department- Hospital da Senhora da Oliveira, Guimarães, Portugal
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18
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Solomon J, Moss E, Morin JF, Langlois Y, Cecere R, de Varennes B, Lachapelle K, Piazza N, Martucci G, Bendayan M, Piankova P, Hayman V, Ouimet MC, Rudski LG, Afilalo J. The Essential Frailty Toolset in Older Adults Undergoing Coronary Artery Bypass Surgery. J Am Heart Assoc 2021; 10:e020219. [PMID: 34315236 PMCID: PMC8475706 DOI: 10.1161/jaha.120.020219] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
Abstract
Background The Essential Frailty Toolset (EFT) was shown to be easy to use and predictive of adverse events in patients undergoing aortic valve replacement procedures. The objective of this study was to evaluate the EFT in patients undergoing coronary artery bypass grafting procedures. Methods and Results The McGill Frailty Registry prospectively included patients ≥60 years of age undergoing urgent or elective isolated coronary artery bypass grafting between 2011 and 2018 at 2 hospitals. The preoperative EFT was scored 0 to 5 points as a function of timed chair rises, Mini-Mental Status Examination, serum albumin, and hemoglobin. The primary outcome was all-cause mortality assessed by Cox proportional hazards regression. The cohort consisted of 500 patients with a mean age of 71.4 ± 6.4 years, of which 27% presented with acute coronary syndromes requiring urgent surgery. The mean EFT was 1.3 ± 1.1 points, 132 (26%) were nonfrail, 298 (60%) were prefrail, and 70 (14%) were frail. Over a median follow-up of 4.0 years, 78 deaths were observed. In nonfrail, prefrail, and frail patients, survival at 1 year was 98%, 95%, and 91%, and at 5 years was 89%, 83%, and 63% (P<0.001). After adjustment, each incremental EFT point was associated with a hazard ratio of 1.28 (95% CI, 1.05-1.56) and frail patients had a 3-fold increase in all-cause mortality. Conclusions The EFT is a pragmatic and highly prognostic tool to assess frailty and guide decisions for coronary artery bypass grafting in older adults. Furthermore, the EFT may be actionable through targeted interventions such as cardiac rehabilitation and nutritional optimization.
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Affiliation(s)
- Joshua Solomon
- Centre for Clinical Epidemiology Lady Davis Institute for Medical ResearchJewish General Hospital Montreal QC Canada
| | - Emmanuel Moss
- Division of Cardiac Surgery Jewish General HospitalMcGill University Montreal QC Canada
| | - Jean-Francois Morin
- Division of Cardiac Surgery Jewish General HospitalMcGill University Montreal QC Canada
| | - Yves Langlois
- Division of Cardiac Surgery Jewish General HospitalMcGill University Montreal QC Canada
| | - Renzo Cecere
- Division of Cardiac Surgery McGill University Health Centre Montreal QC Canada
| | - Benoit de Varennes
- Division of Cardiac Surgery McGill University Health Centre Montreal QC Canada
| | - Kevin Lachapelle
- Division of Cardiac Surgery McGill University Health Centre Montreal QC Canada
| | - Nicolo Piazza
- Division of Cardiology McGill University Health Centre Montreal QC Canada
| | - Giuseppe Martucci
- Division of Cardiology McGill University Health Centre Montreal QC Canada
| | - Melissa Bendayan
- Centre for Clinical Epidemiology Lady Davis Institute for Medical ResearchJewish General Hospital Montreal QC Canada
| | - Palina Piankova
- Centre for Clinical Epidemiology Lady Davis Institute for Medical ResearchJewish General Hospital Montreal QC Canada
| | - Victoria Hayman
- Centre for Clinical Epidemiology Lady Davis Institute for Medical ResearchJewish General Hospital Montreal QC Canada
| | | | - Lawrence G Rudski
- Division of Cardiology Jewish General HospitalMcGill University Montreal QC Canada
| | - Jonathan Afilalo
- Centre for Clinical Epidemiology Lady Davis Institute for Medical ResearchJewish General Hospital Montreal QC Canada.,Research InstituteMcGill University Health Centre Montreal QC Canada.,Division of Cardiology Jewish General HospitalMcGill University Montreal QC Canada
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19
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Houghton JS, Nickinson AT, Helm JR, Dimitrova J, Dubkova S, Rayt HS, Gray LJ, Haunton VJ, Davies RS, Sayers RD. Associations of Clinical Frailty with Severity of Limb Threat and Outcomes in Chronic Limb-threatening Ischaemia. Ann Vasc Surg 2021; 76:406-416. [PMID: 33951523 DOI: 10.1016/j.avsg.2021.04.017] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2021] [Revised: 03/25/2021] [Accepted: 04/03/2021] [Indexed: 10/21/2022]
Abstract
OBJECTIVE Investigate the relationship of frailty and severity of chronic limb-threatening ischaemia (CLTI), and their comparative associations with one-year outcomes, in patients presenting to a vascular limb salvage (VaLS) clinic. METHODS This retrospective cohort study utilised data collected from a prospectively maintained VaLS clinic database. Patients aged ≥50 presenting to the VaLS clinic with CLTI between February 2018 and April 2019 were included. Frailty was measured using the Clinical Frailty Scale (CFS) and limb threat severity by the Wound, Ischaemia, and foot Infection (WIfI) score. Excessive polypharmacy was defined as ≥10 medications. Anticholinergic burden (ACB) score and Charlson comorbidity index (CCI) were calculated for all patients. The primary outcome measure was a composite endpoint of death or amputation at one-year. Associations with outcome were assessed using Cox regression and reported as hazards ratios (HR) with 95% confidence intervals (CI). RESULTS A total of 198 patients were included, with CFS scores available for 190 patients. 98 patients (52%) were frail (CFS ≥5). 127 patients (67%) initially underwent endovascular revascularisation. Excessive polypharmacy was common (55 patients; 28%). Frailty was associated with increased WIfI stage (P = 0.025) as well as age, female sex, CCI score, number of medications, excessive polypharmacy but not ACB score. Frail patients were more frequently managed non-operatively (P = 0.017). Frailty (HR 1.91; 95% CI 1.09, 3.34; P = 0.024) and WIfI stage 4 (HR 3.29; 95%CI 1.23, 8.80; P = 0.018) were associated with death or amputation on univariable analysis. WIfI stage 4 (HR 2.80; 95%CI 1.04, 7.57; P = 0.042) and CCI score (HR 1.21; 95%CI 1.03, 1.41; P = 0.015), but not frailty (HR 1.25; 95%CI 0.67, 2.33; P = 0.474), were independently associated with death or amputation on multivariable analysis. CONCLUSIONS Frailty is highly prevalent among CLTI patients and related to severity of limb threat. The CFS may be a useful adjunct to patient risk assessment in CLTI.
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Affiliation(s)
- John Sm Houghton
- Department of Cardiovascular Sciences, University of Leicester, UK; Leicester Vascular Institute, University Hospitals of Leicester NHS Trust, UK; National Institute for Health Research Leicester Biomedical Research Centre - The Glenfield Hospital, Leicester, UK.
| | - Andrew To Nickinson
- Department of Cardiovascular Sciences, University of Leicester, UK; Leicester Vascular Institute, University Hospitals of Leicester NHS Trust, UK; National Institute for Health Research Leicester Biomedical Research Centre - The Glenfield Hospital, Leicester, UK
| | - Jessica R Helm
- Leicester Vascular Institute, University Hospitals of Leicester NHS Trust, UK
| | - Jivka Dimitrova
- Leicester Vascular Institute, University Hospitals of Leicester NHS Trust, UK
| | - Svetlana Dubkova
- Leicester Vascular Institute, University Hospitals of Leicester NHS Trust, UK
| | - Harjeet S Rayt
- Department of Cardiovascular Sciences, University of Leicester, UK; Leicester Vascular Institute, University Hospitals of Leicester NHS Trust, UK
| | - Laura J Gray
- Department of Health Sciences, University of Leicester, UK
| | | | - Robert Sm Davies
- Leicester Vascular Institute, University Hospitals of Leicester NHS Trust, UK
| | - Rob D Sayers
- Department of Cardiovascular Sciences, University of Leicester, UK; Leicester Vascular Institute, University Hospitals of Leicester NHS Trust, UK; National Institute for Health Research Leicester Biomedical Research Centre - The Glenfield Hospital, Leicester, UK
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20
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Houghton JSM, Nickinson ATO, Bridgwood B, Nduwayo S, Pepper CJ, Rayt HS, Gray LJ, Haunton VJ, Sayers RD. Prevalence of Cognitive Impairment in Individuals with Vascular Surgical Pathology: a Systematic Review and Meta-Analysis. Eur J Vasc Endovasc Surg 2021; 61:664-674. [PMID: 33573912 DOI: 10.1016/j.ejvs.2020.12.016] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2020] [Revised: 12/02/2020] [Accepted: 12/17/2020] [Indexed: 12/29/2022]
Abstract
OBJECTIVE A significant proportion of vascular surgery patients may have undiagnosed cognitive impairment; however, its true prevalence and impact on outcomes are unknown. The aim of this review was to estimate the prevalence of cognitive impairment among individuals with clinically significant vascular surgical pathology and investigate its associations with post-operative outcomes in those undergoing vascular surgery. METHODS MEDLINE, EMBASE, EMCare, CINAHL, PsycINFO, and Scopus were searched for relevant studies. Included studies assessed cognitive function among individuals with either symptomatic vascular surgical pathology, or disease above threshold for intervention, using a validated cognitive assessment tool. The primary outcome measure was prevalence of cognitive impairment. Secondary outcomes included incidence of post-operative delirium (POD). Two reviewers independently extracted relevant study data and assessed risk of bias (ROBINS-E or RoB 2 tool). Prevalence (%) of cognitive impairment was calculated for individual studies and presented with 95% confidence intervals (CI). Prevalence data from comparable studies were pooled using the Mantel-Haenszel method (random effects model) for separate vascular disease types. Certainty of effect estimates was assessed using the GRADE criteria. RESULTS Twenty-four studies (2 564 participants) were included in the systematic review, and nine studies (1 310 participants) were included in the meta-analyses. The prevalence of cognitive impairment was 61% (95% CI 48 - 74; 391 participants; low certainty) in studies including multiple vascular surgical pathologies, 38% (95% CI 32 - 44; 278 participants; very low certainty) in carotid artery disease, and 19% (95% CI 10 - 33; 641 participants; low certainty) in those with intermittent claudication. Lower cognitive assessment scores were associated with POD (five studies; 841 participants), but data were not suitable for pooling. CONCLUSION Screening elective vascular surgery patients for cognitive impairment may be appropriate given its high prevalence, and the association of worse cognition with POD, among individuals with clinically significant vascular surgical pathology.
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Affiliation(s)
- John S M Houghton
- Department of Cardiovascular Sciences, University of Leicester, Leicester, UK; Leicester Vascular Institute, University Hospitals of Leicester NHS Trust, Leicester, UK; National Institute for Health Research Leicester Biomedical Research Centre - The Glenfield Hospital, Leicester, UK.
| | - Andrew T O Nickinson
- Department of Cardiovascular Sciences, University of Leicester, Leicester, UK; Leicester Vascular Institute, University Hospitals of Leicester NHS Trust, Leicester, UK; National Institute for Health Research Leicester Biomedical Research Centre - The Glenfield Hospital, Leicester, UK
| | - Bernadeta Bridgwood
- Department of Cardiovascular Sciences, University of Leicester, Leicester, UK
| | - Sarah Nduwayo
- Department of Cardiovascular Sciences, University of Leicester, Leicester, UK; Leicester Vascular Institute, University Hospitals of Leicester NHS Trust, Leicester, UK; National Institute for Health Research Leicester Biomedical Research Centre - The Glenfield Hospital, Leicester, UK
| | - Coral J Pepper
- Library Service, University Hospitals of Leicester NHS Trust, Leicester, UK
| | - Harjeet S Rayt
- Department of Cardiovascular Sciences, University of Leicester, Leicester, UK; Leicester Vascular Institute, University Hospitals of Leicester NHS Trust, Leicester, UK
| | - Laura J Gray
- Department of Health Sciences, University of Leicester, Leicester, UK
| | - Victoria J Haunton
- Department of Cardiovascular Sciences, University of Leicester, Leicester, UK
| | - Rob D Sayers
- Department of Cardiovascular Sciences, University of Leicester, Leicester, UK; Leicester Vascular Institute, University Hospitals of Leicester NHS Trust, Leicester, UK; National Institute for Health Research Leicester Biomedical Research Centre - The Glenfield Hospital, Leicester, UK
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21
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Soon SX, D'Çruz R, Yap CJ, Tay WL, Chng SP, Choke ET, Chong TT, Wong TH, Tang TY. The modified frailty index-11 predicts medium-term outcomes after endovascular revascularisation for chronic limb threatening ischaemia in Asian patients. Vascular 2021; 30:42-51. [PMID: 33491572 DOI: 10.1177/1708538120988228] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
OBJECTIVE The aim was to evaluate the utility of frailty, as defined by the modified Frailty Index-1 1 (mFI-11) on predicting outcomes following endovascular revascularisation in Asian patients with chronic limb-threatening ischaemia (CLTI). METHODS CLTI patients who underwent endovascular revascularisation between January 2015 and March 2017 were included. Patients were retrospectively scored using the mFI-11 to categorise frailty as low, medium or high risk. Observed outcomes included 30-day complication rate and unplanned readmissions, 1-, 6- and 12-month mortality, and ambulation status at 6- and 12 months post-intervention. RESULTS A total of 233 patients (250 procedures) were included; 137 (58.8%) were males and the mean age was 69.0 (±10.7) years. 202/233 (86.7%) were diabetic and 196/233 (84.1%) had a prior diagnosis of peripheral arterial disease (PAD). The mean mFI-11 score was 4.2 (±1.5). 28/233 (12.0%), 155/233 (66.5%), and 50/233 (21.5%) patients were deemed low (mF-11 score 0-2), moderate (mFI-11 score 3-5) and high (mFI-11 score 5-7) frailty risk, respectively. High frailty was associated with an increased 12-month mortality (OR 8.54, 95% CI 1.05-69.5; p = 0.05), 30-day complication rate (OR 9.41, 95% CI 2.01-44.1; p < 0.01) and 30-day unplanned readmission (OR 5.06, 95% CI 1.06-24.2; p = 0.04). Furthermore, a high score was associated with a significantly worse 6- (OR 0.320, 95% CI 0.120-0.840; p = 0.02) and 12-month (OR 0.270, 95% CI 0.100-0.710; p < 0.01) ambulatory status. CONCLUSION The mFI-11 is a useful, non-invasive tool that can be readily calculated using readily available patient data, for prediction of medium-term outcomes for Asian CLTI patients following endovascular revascularisation. Early recognition of short- and mid-term loss of ambulation status amongst high-frailty patients in this challenging cohort of patients could aid decision-making for whether a revascularisation or amputation-first policy is appropriate, and manage patient and caregiver expectations on potential improvement in functional outcome.
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Affiliation(s)
- Shereen Xy Soon
- Department of Vascular Surgery, Singapore General Hospital, Singapore, Singapore
| | | | - Charyl Jq Yap
- Department of Vascular Surgery, Singapore General Hospital, Singapore, Singapore
| | - Wei Ling Tay
- Department of Vascular Surgery, Singapore General Hospital, Singapore, Singapore
| | - Siew Ping Chng
- Department of Vascular Surgery, Singapore General Hospital, Singapore, Singapore
| | - Edward Tc Choke
- Department of General Surgery, Sengkang General Hospital, Singapore, Singapore
| | - Tze Tec Chong
- Department of Vascular Surgery, Singapore General Hospital, Singapore, Singapore
| | - Ting Hway Wong
- Department of General Surgery, Singapore General Hospital, Singapore, Singapore
| | - Tjun Y Tang
- Department of Vascular Surgery, Singapore General Hospital, Singapore, Singapore.,Duke NUS Medical Graduate School, Singapore, Singapore
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22
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Banning LBD, El Moumni M, Visser L, van Leeuwen BL, Zeebregts CJ, Pol RA. Frailty leads to poor long-term survival in patients undergoing elective vascular surgery. J Vasc Surg 2020; 73:2132-2139.e2. [PMID: 33387657 DOI: 10.1016/j.jvs.2020.10.088] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/26/2020] [Accepted: 10/29/2020] [Indexed: 01/04/2023]
Abstract
OBJECTIVE Frailty has persistently been associated with unfavorable short-term outcomes after vascular surgery, including an increased complication risk, greater readmission rate, and greater short-term mortality. However, a knowledge gap remains concerning the association between preoperative frailty and long-term mortality. In the present study, we aimed to determine this association in elective vascular surgery patients. METHODS The present study was a part of a large prospective cohort study initiated in 2010 in our tertiary referral teaching hospital to study frailty in elderly elective vascular surgery patients (Vascular Ageing Study). A total of 639 patients with a minimal follow-up of 5 years, who had been treated from 2010 to 2014, were included in the present study. The Groningen Frailty Indicator, a 15-item self-administered questionnaire, was used to determine the presence and degree of frailty. RESULTS Of the 639 patients, 183 (28.6%) were considered frail preoperatively. For the frail patients, the actuarial survival after 1, 3, and 5 years was 81.4%, 66.7%, and 55.7%, respectively. For the nonfrail patients, the corresponding survival was 93.6%, 83.3%, and 75.2% (log-rank test, P < .001). Frail patients had a significantly greater risk of 5-year mortality (unadjusted hazard ratio, 2.09; 95% confidence interval, 1.572-2.771; P < .001). After adjusting for surgical- and patient-related risk factors, the hazard ratio was 1.68 (95% confidence interval, 1.231-2.286; P = .001). CONCLUSIONS The results of our study have shown that preoperative frailty is associated with significantly increased long-term mortality after elective vascular surgery. Knowledge of a patient's preoperative frailty state could, therefore, be helpful in shared decision-making, because it provides more information about the procedural benefits and risks.
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Affiliation(s)
- Louise B D Banning
- Division of Vascular Surgery, Department of Surgery, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - Mostafa El Moumni
- Division of Trauma Surgery, Department of Surgery, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - Linda Visser
- Division of Vascular Surgery, Department of Surgery, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - Barbara L van Leeuwen
- Division of Surgical Oncology, Department of Surgery, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - Clark J Zeebregts
- Division of Vascular Surgery, Department of Surgery, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - Robert A Pol
- Division of Vascular Surgery, Department of Surgery, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands.
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23
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Prognostic effect of the new 5-factor modified frailty index in patients undergoing carotid endarterectomy with regional anesthesia – A prospective cohort study. Int J Surg 2020; 80:27-34. [DOI: 10.1016/j.ijsu.2020.05.074] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2020] [Revised: 05/19/2020] [Accepted: 05/23/2020] [Indexed: 12/21/2022]
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24
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Transitions in frailty state after kidney transplantation. Langenbecks Arch Surg 2020; 405:843-850. [PMID: 32691130 PMCID: PMC7471154 DOI: 10.1007/s00423-020-01936-6] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/02/2020] [Accepted: 07/10/2020] [Indexed: 02/07/2023]
Abstract
PURPOSE Frailty is the body's failure to return to homeostasis after every day or acute stressful events, causing adverse outcomes. To study its dynamics in kidney transplant recipients (KTR), we determined whether the degree of frailty and its domains are affected by kidney transplantation (KT). METHODS Between 2015 and 2017, 176 KTR were included. Frailty scores were measured using the Groningen Frailty Indicator (GFI), assessed preoperatively and during follow-up. Transitions in frailty state and changes in the individual domains were determined. RESULTS Mean age (±SD) was 51.8 (± 14.1) years, and 63.1% of KTR were male. Thirty patients were considered frail (GFI ≥ 4) at baseline. After a mean follow-up of 22.8 ± 8.3 months, 34 non-frail patients (19.3%) became frail, 125 patients (71.0%) remained the same, and 17 frail patients (9.7%) became non-frail (GFI < 4). In the domain psychosocial functioning, 28.4% of the patients had an increase in GFI score after follow-up. Patients who scored a point in the domain cognition at baseline had a greater chance of becoming frail (OR 4.38, 95% CI 0.59-32.24). CONCLUSION In conclusion, almost one-fifth of non-frail KTR transitioned to a frail state after their transplantation. These results could be used to predict the impact of KT on frailty course and help with implementing prehabilitation for patients at risk.
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25
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Pilotto A, Custodero C, Maggi S, Polidori MC, Veronese N, Ferrucci L. A multidimensional approach to frailty in older people. Ageing Res Rev 2020; 60:101047. [PMID: 32171786 PMCID: PMC7461697 DOI: 10.1016/j.arr.2020.101047] [Citation(s) in RCA: 168] [Impact Index Per Article: 42.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2019] [Revised: 02/13/2020] [Accepted: 03/10/2020] [Indexed: 12/13/2022]
Abstract
Frailty is an important factor determining a higher risk of adverse health outcomes in older adults. Although scientific community in the last two decades put a lot of effort for its definition, to date no consensus was reached on its assessment. The mainstream thinking describes frailty as a loss of physical functions or as accumulation of multiple deficits. Recently, a novel conceptual model of frailty has emerged based on the loss of harmonic interaction between multiple domains (also referred as dimensions) including genetic, biological, functional, cognitive, psychological and socio-economic domain that ultimately lead to homeostatic instability. Therefore, the multidimensional aspects of frailty condition could be captured by the comprehensive geriatric assessment (CGA) and its derived Multidimensional Prognostic Index (MPI). This instrument has been applied in different clinical settings and in several cohorts of older adults with specific acute and chronic diseases, showing always excellent accuracy in stratifying population according the mortality risk and other negative health outcomes, i.e. hospitalization, institutionalization or admission to homecare services. This MPI "plasticity" provides a single numerical prognostic index which could be helpful in clinical decision making for the management of frail older adults.
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Affiliation(s)
- Alberto Pilotto
- Department of Interdisciplinary Medicine, University of Bari Aldo Moro, Bari, Italy; Geriatrics Unit, Department of Geriatric Care, Orthogeriatrics and Rehabilitation, E.O. Ospedali Galliera, Genova, Italy.
| | - Carlo Custodero
- Department of Interdisciplinary Medicine, University of Bari Aldo Moro, Bari, Italy
| | - Stefania Maggi
- National Research Council (CNR), Aging Section, Padova, Italy
| | | | - Nicola Veronese
- Geriatrics Unit, Department of Geriatric Care, Orthogeriatrics and Rehabilitation, E.O. Ospedali Galliera, Genova, Italy; Azienda ULSS 3 Serenissima, Primary Care Department, District 3, Venice, Italy
| | - Luigi Ferrucci
- National Institute on Aging, NIH, Baltimore, MD, United States
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26
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Abstract
Perioperative management of older adults is a complex field that is heavily influenced by the clinical heterogeneity of older adults. Frailty-a geriatric syndrome in which a patient is more vulnerable to stressors due to decreases in physical function and reserve-has been indicative of adverse postoperative outcomes. Many tools have been developed to measure frailty that incorporate a variety of factors including physical and cognitive function, comorbidities, self-reported measures of health, and clinical judgment. Most of these frailty assessment tools are able to identify a subset of patients at risk of adverse outcomes including postoperative complications, longer hospital length of stay, discharge to a higher level of care, and mortality. Frailty assessment before surgical interventions can also guide discussions among patients, their families, anesthesiologists, and surgeons to tailor operative plans for patients to mitigate this increased risk. Studies are ongoing to identify interventions in frail patients that can improve postoperative outcomes, but high-quality data in the form of randomized controlled trials are lacking at this time.
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Cha JJ, Kim H, Ko YG, Choi D, Lee JH, Yoon CH, Chae IH, Yu CW, Lee SW, Lee SR, Choi SH, Koh YS, Min PK. Influence of preprocedural glycemic control on clinical outcomes of endovascular therapy in diabetic patients with lower extremity artery disease: an analysis from a Korean multicenter retrospective registry cohort. Cardiovasc Diabetol 2020; 19:97. [PMID: 32571352 PMCID: PMC7310391 DOI: 10.1186/s12933-020-01072-x] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/04/2020] [Accepted: 06/16/2020] [Indexed: 12/13/2022] Open
Abstract
BACKGROUND The influence of intensive glucose control in diabetic patients on the macrovascular outcomes is controversial. Thus, this study aimed to elucidate the effect of preprocedural hemoglobin A1c (HbA1c) on clinical outcomes after endovascular therapy for lower extremity artery disease (LEAD) in diabetic patients. METHODS Diabetic patients were enrolled from the retrospective cohorts of a Korean multicenter endovascular therapy registry and were divided according to the HbA1c level during index admission into the optimal (< 7.0%) or suboptimal (≥ 7.0%) glycemic control groups. The primary endpoints were major adverse limb events (MALE, a composite of major amputation, minor amputation, and reintervention). RESULTS Of the 1103 patients enrolled (897 men, mean age 68.2 ± 8.9 years), 432 (39.2%) were classified into the optimal glycemic control group and 671 (60.8%) into the suboptimal glycemic control group. In-hospital events and immediate procedural complications were not different between the two groups. The suboptimal group showed a trend towards a higher incidence of MALE than the optimal group (log-rank p = 0.072). Although no significant differences were found between the two groups in terms of overall survival or amputation, the risk of reintervention was significantly higher in the suboptimal group (log-rank p = 0.048). In the multivariate Cox regression model, suboptimal glycemic control was one of the independent predictors for reintervention. When our data were analyzed according to the initial presentation, suboptimal preprocedural HbA1c significantly increased the incidence of MALE compared with optimal preprocedural HbA1c only in patients with intermittent claudication. CONCLUSION In diabetic patients undergoing endovascular therapy for LEAD, suboptimal preprocedural HbA1c is associated with an increased risk of adverse limb events, especially in patients with intermittent claudication. Further prospective research will be required to validate the role of more intensive glycemic control on the reduction of adverse limb events in diabetic patients undergoing endovascular therapy for LEAD.
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Affiliation(s)
- Jung-Joon Cha
- Division of Cardiology, Department of Internal Medicine, Severance Cardiovascular Hospital, Yonsei University College of Medicine, Seoul, South Korea.,Division of Cardiology, Department of Internal Medicine, Korea University Anam Hospital, Seoul, South Korea
| | - Hyoeun Kim
- Division of Cardiology, Department of Internal Medicine, Severance Cardiovascular Hospital, Yonsei University College of Medicine, Seoul, South Korea.,Department of Health Promotion, Health Promotion Center, Severance Hospital, Yonsei University Health System, Seoul, South Korea
| | - Young-Guk Ko
- Division of Cardiology, Department of Internal Medicine, Severance Cardiovascular Hospital, Yonsei University College of Medicine, Seoul, South Korea
| | - Donghoon Choi
- Division of Cardiology, Department of Internal Medicine, Severance Cardiovascular Hospital, Yonsei University College of Medicine, Seoul, South Korea
| | - Jae-Hwan Lee
- Division of Cardiology, Department of Internal Medicine, Chungnam National University Hospital, Daejeon, South Korea
| | - Chang-Hwan Yoon
- Division of Cardiology, Seoul National University Bundang Hospital, Seoungnam, South Korea
| | - In-Ho Chae
- Division of Cardiology, Seoul National University Bundang Hospital, Seoungnam, South Korea
| | - Cheol Woong Yu
- Division of Cardiology, Department of Internal Medicine, Korea University Anam Hospital, Seoul, South Korea
| | - Seung Whan Lee
- Division of Cardiology, Department of Internal Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul, South Korea
| | - Sang-Rok Lee
- Division of Cardiology, Department of Internal Medicine, Chonbuk National University Hospital, Jeonju, South Korea
| | - Seung Hyuk Choi
- Division of Cardiology, Department of Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, South Korea
| | - Yoon Seok Koh
- Division of Cardiology, Department of Internal Medicine, Seoul St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, South Korea.,Division of Cardiology, Hallym University Sacred Heart Hospital, Anyang, South Korea
| | - Pil-Ki Min
- Division of Cardiology, Department of Internal Medicine, Gangnam Severance Hospital, Yonsei University College of Medicine, 20, Eonju-ro 63-gil, Gangnam-gu, Seoul, 06229, South Korea.
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Haren A, Lal R, Walker D, Nair R, Partridge J, Dhesi J. Frailty assessment in older urological patients prior to surgery: a systematic review and narrative synthesis. Ther Adv Urol 2020; 12:1756287220916614. [PMID: 32435276 PMCID: PMC7225795 DOI: 10.1177/1756287220916614] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/10/2019] [Accepted: 03/07/2020] [Indexed: 01/30/2023] Open
Abstract
Background: Radical cystectomy (RC) and urinary diversion are the recommended treatment for patients with muscle invasive bladder cancer. This is complex surgery, associated with significant patient morbidity and mortality. Frailty has been shown to be an independent risk factor for adverse outcomes in several surgical populations. Preoperative assessment of frailty is advocated in current guidelines but is not yet standard clinical practice. Aims: This systematic review and narrative synthesis aims to examine whether patients undergoing RC are assessed for frailty, what tools are used, and whether an association is found between frailty and adverse outcomes in this population. Results: Nine studies, published within the last 4 years, describe the use of tools reporting to measure frailty in the RC population. All demonstrate increased risk of adverse postoperative outcomes with higher frailty levels. Only one study used a validated frailty tool. The majority of studies measure frailty using variations on a tool derived from a large database (ACS-NSQIP) effectively counting co-morbidities, rather than assessing the multidomain nature of the frailty syndrome. Conclusion: The recognition of frailty as an important consideration in the perioperative period is welcome. This systematic review and narrative synthesis demonstrates the need for collaboration in research and delivery of clinical care for older surgical patients. Such collaboration may provide clarity regarding terms such as frailty and multimorbidity, preventing the development of assessment tools inaccurately measuring these discreet syndromes interchangeably. More accurate assessment of patients in terms of frailty, multimorbidity and functional status may allow better modification and shared decision making leading to improved postoperative outcomes in older patients undergoing RC.
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Affiliation(s)
- Andrea Haren
- Perioperative Medicine Fellow, Department of Anaesthesia and Perioperative Medicine, University College London Hospitals, London, UK
| | - Rajni Lal
- Perioperative Care of Older People undergoing Surgery (POPS) Fellow, Department of Ageing and Health, Guy's and St Thomas' NHS Foundation Trust, London, UK
| | - David Walker
- Department of Anaesthesia and Perioperative Medicine, University College London Hospitals, London, UK
| | - Rajesh Nair
- Consultant Urological Surgeon, Department of Urology, Guy's and St. Thomas' NHS Foundation Trust, London, UK
| | - Judith Partridge
- Perioperative Care of Older People undergoing Surgery (POPS), Department of Ageing and Health, Guy's and St Thomas' NHS Foundation Trust, London, UK
| | - Jugdeep Dhesi
- Perioperative Care of Older People undergoing Surgery (POPS), Department of Ageing and Health, Guy's and St Thomas' NHS Foundation Trust, London, SE1 9RT, UK
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Reeve TE, Craven TE, Goldman MP, Hurie JB, Velazquez-Ramirez G, Edwards MS, Corriere MA. Outpatient grip strength measurement predicts survival, perioperative adverse events, and nonhome discharge among patients with vascular disease. J Vasc Surg 2020; 73:250-257. [PMID: 32360376 DOI: 10.1016/j.jvs.2020.03.060] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/12/2019] [Accepted: 03/20/2020] [Indexed: 01/24/2023]
Abstract
OBJECTIVES Frailty is associated with adverse outcomes among patients with vascular disease. Grip strength measurement is a comparatively simple, quick, and inexpensive screening test for weakness (a component of frailty) that is potentially applicable to clinical practice. We hypothesized that grip strength and categorical weakness are associated with clinical outcomes among patients with vascular disease. To test this hypothesis, we conducted a longitudinal cohort study evaluating associations between grip strength measured during outpatient clinic visits for vascular disease and clinical outcomes, including survival and perioperative outcomes. METHODS Adult patients recruited from outpatient vascular surgery and/or vascular medicine clinics underwent dominant hand grip strength measurement using a hand dynamometer. Participants were categorized as weak based on grip strength, sex, and body mass index. Multivariable logistic models were used to evaluate perioperative outcomes. Mortality was evaluated using Cox proportional hazards models adjusted for sex, age, and operative intervention during follow-up. RESULTS We enrolled 321 participants. The mean patients age was 69.0 ± 9.4 years, and 33% were women. Mean grip strength was 32.0 ± 12.1 kg, and 92 participants (29%) were categorized as weak. The median follow-up was 24.0 months. Adverse perioperative events occurred in 32 of 84 patients undergoing procedures. Grip strength was associated with decreased risk of perioperative adverse events (hazard ratio [HR], 0.41 per 12.7 kg increase; 95% confidence interval [CI], 0.20-0.85; P = .0171) in a model adjusted for open versus endovascular procedure (HR, 12.75 for open; 95% CI, 2.54-63.90; P = .0020) and sex (HR, 3.05 for male; 95% CI, 0.75-12.4; P = .120). Grip strength was also associated with a lower risk of nonhome discharge (HR, 0.34 per 12.7 kg increase; 95% CI, 0.14-0.82; P = .016) adjusted for sex (HR, 2.14 for male; 95% CI, 0.48-9.50; P = .31) and open versus endovascular procedure (HR, 10.36 for open; 95% CI, 1.20-89.47; P = .034). No associations between grip strength and length of stay were observed. Mortality occurred in 48 participants (14.9%) during follow-up. Grip strength was inversely associated with mortality (HR, 0.46 per 12.5 kg increase; 95% CI, 0.29-0.73; P = .0009) in a model adjusted for sex (HR, 5.08 for male; 95% CI, 2.1-12.3; P = .0003), age (HR, 1.04 per year; 95% CI, 1.01-1.08), and operative intervention during follow-up (HR, 1.23; 95% CI, 0.71-2.52). Categorical weakness was also associated with mortality (HR, 1.81 vs nonfrail; P = .048) in a model adjusted for age (HR, 1.06 per year; P = .002) and surgical intervention (HR, 1.36; 95% CI, 1.02-0.09; P = .331). CONCLUSIONS Grip strength is associated with all-cause mortality, perioperative adverse events, and nonhome discharge among patients with vascular disease. These observations support the usefulness of grip strength as a simple and inexpensive risk screening tool for patients with vascular disease.
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Affiliation(s)
- Thomas E Reeve
- Department of Vascular and Endovascular Surgery, Wake Forest University School of Medicine, Winston-Salem, NC
| | - Timothy E Craven
- Department of Biostatistical Sciences, Wake Forest University School of Medicine, Winston-Salem, NC
| | - Matthew P Goldman
- Department of Vascular and Endovascular Surgery, Wake Forest University School of Medicine, Winston-Salem, NC
| | - Justin B Hurie
- Department of Vascular and Endovascular Surgery, Wake Forest University School of Medicine, Winston-Salem, NC
| | - Gabriela Velazquez-Ramirez
- Department of Vascular and Endovascular Surgery, Wake Forest University School of Medicine, Winston-Salem, NC
| | - Matthew S Edwards
- Department of Vascular and Endovascular Surgery, Wake Forest University School of Medicine, Winston-Salem, NC
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