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El Hajj M, Hadid B, Rosenzveig A, Hadid S, Frishman WH, Aronow WS. Managing the Intricacies of Coronary Revascularization: A Close Look at the Complete Versus Culprit-Only Approach and its Implications in Elderly Patients. Cardiol Rev 2024:00045415-990000000-00293. [PMID: 38970477 DOI: 10.1097/crd.0000000000000752] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 07/08/2024]
Abstract
Coronary heart disease is the leading cause of mortality in the United States, and data indicates that 805,000 Americans will face a new or recurrent myocardial infarction (MI) attack every year. Frailty, a conceptual syndrome categorized by a functional decline that occurs with aging, has been linked to adverse health outcomes in cardiovascular disease and all cardiac-related procedures in general. It is therefore reasonable to deliberate that more conservative medical therapy or medical management should be considered in the frail population when managing acute coronary syndrome. This course of action has, in fact, been documented in clinical practice. However, the recent Functional Assessment in Elderly MI Patients with Multivessel Disease trial, in which all subjects were 75 years of age or above, indicated that the more invasive complete revascularization approach may be favorable over incomplete or culprit-only revascularization in patients with acute MI. In this review, we will discuss coronary heart disease and review guidelines and procedures for culprit lesion identification, including electrocardiogram procedures, coronary angiography, intravascular ultrasound, fractional flow reserve, and instantaneous fractional flow reserve. We then discuss the concept of complete vs culprit-only/incomplete coronary revascularization and staging. Following this, we will delve into recent trials discussing complete vs culprit-only revascularization, emphasizing the insights gleaned from this latest trial within this special frailty cohort which warrants special consideration.
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Affiliation(s)
- Mahmoud El Hajj
- From the Department of Internal Medicine, Montefiore St. Luke's Cornwall Hospital, Newburgh, NY
| | - Bana Hadid
- Department of Medicine, NewYork-Presbyterian/Columbia University Irving Medical Center, New York, NY
| | - Akiva Rosenzveig
- Department of Internal Medicine, Cleveland Clinic Foundation, Cleveland, OH
| | - Somar Hadid
- Department of Medicine, New York Medical College, Valhalla, NY
| | - William H Frishman
- Department of Medicine, New York Medical College, Valhalla, NY
- Department of Medicine, Westchester Medical Center, Valhalla, NY
- Department of Cardiology, Westchester Medical Center, Valhalla, NY
| | - Wilbert S Aronow
- Department of Medicine, New York Medical College, Valhalla, NY
- Department of Medicine, Westchester Medical Center, Valhalla, NY
- Department of Cardiology, Westchester Medical Center, Valhalla, NY
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Montgomery C, Stelfox H, Norris C, Rolfson D, Meyer S, Zibdawi M, Bagshaw S. Association between preoperative frailty and outcomes among adults undergoing cardiac surgery: a prospective cohort study. CMAJ Open 2021; 9:E777-E787. [PMID: 34285057 PMCID: PMC8313095 DOI: 10.9778/cmajo.20200034] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
BACKGROUND The identification of frailty before complex and invasive procedures may have relevance for prognostic and recovery purposes, to optimally inform patients, caregivers and clinicians about perioperative risk and postoperative care needs. The aim of this study was to estimate the prevalence of frailty and describe the associated clinical course and outcomes of patients referred for nonemergent cardiac surgery. METHODS A prospective cohort of patients aged 50 years and older referred for nonemergent cardiac surgery in Alberta, Canada, from November 2011 to March 2014 were screened preoperatively for frailty, defined as a Clinical Frailty Scale (CFS) score of 5 or greater. Postoperatively, patients were followed by telephone to assess CFS score, health services use and vital status. The primary outcome was all-cause hospital mortality. Secondary outcomes included health services use, hospital discharge disposition, 1-year health-related quality of life and all-cause 5-year mortality. RESULTS The cohort (n = 529) had a mean age of 67 (standard deviation [SD] 9) years; 25.9% were female, and the prevalence of frailty was 9.6% (n = 51; 95% confidence interval [CI] 7.3%-12.5%). Frail patients were older (median age 75, interquartile range [IQR] 65-80 v. 67, IQR 60-73, yr; p < 0.001), were more likely to be female (51.0% v. 23.2%; p < 0.001), had a higher mean EuroSCORE II (8, SD 3 v. 5, SD 3; p < 0.001) and received combined coronary artery bypass grafting and valve procedures more frequently (29.4% v. 15.9%; p = 0.02) than nonfrail patients. Postoperatively, frail patients had a longer median duration of stay in the cardiovascular intensive care unit (median difference 2.2, 95% CI 1.60-2.79) and hospital (median difference 9.3, 95% CI 8.2-10.3). Hospital mortality was 9.8% among frail patients and 1.0% among nonfrail patients (adjusted hazard ratio 3.84, 95% CI 0.90-16.34). INTERPRETATION Preoperative frailty was present in 10% of patients and was associated with a higher risk of morbidity and greater health services use. Preoperative frailty has important implications for the postoperative clinical course and resource utilization of patients undergoing cardiac surgery.
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Affiliation(s)
- Carmel Montgomery
- Department of Critical Care Medicine (Montgomery, Zibdawi, Bagshaw), Faculty of Medicine & Dentistry, University of Alberta, Edmonton, Alta.; Department of Critical Care Medicine (Stelfox), Cumming School of Medicine, and Department of Community Health Sciences (Stelfox), University of Calgary, Calgary, Alta.; Faculty of Nursing and School of Public Health (Norris, Bagshaw), University of Alberta; Strategic Clinical Networks (Norris, Bagshaw), Alberta Health Services; Division of Geriatric Medicine (Rolfson), Department of Medicine, and Division of Cardiac Surgery, (Meyer) Department of Surgery, Faculty of Medicine & Dentistry, University of Alberta, Edmonton, Alta.
| | - Henry Stelfox
- Department of Critical Care Medicine (Montgomery, Zibdawi, Bagshaw), Faculty of Medicine & Dentistry, University of Alberta, Edmonton, Alta.; Department of Critical Care Medicine (Stelfox), Cumming School of Medicine, and Department of Community Health Sciences (Stelfox), University of Calgary, Calgary, Alta.; Faculty of Nursing and School of Public Health (Norris, Bagshaw), University of Alberta; Strategic Clinical Networks (Norris, Bagshaw), Alberta Health Services; Division of Geriatric Medicine (Rolfson), Department of Medicine, and Division of Cardiac Surgery, (Meyer) Department of Surgery, Faculty of Medicine & Dentistry, University of Alberta, Edmonton, Alta
| | - Colleen Norris
- Department of Critical Care Medicine (Montgomery, Zibdawi, Bagshaw), Faculty of Medicine & Dentistry, University of Alberta, Edmonton, Alta.; Department of Critical Care Medicine (Stelfox), Cumming School of Medicine, and Department of Community Health Sciences (Stelfox), University of Calgary, Calgary, Alta.; Faculty of Nursing and School of Public Health (Norris, Bagshaw), University of Alberta; Strategic Clinical Networks (Norris, Bagshaw), Alberta Health Services; Division of Geriatric Medicine (Rolfson), Department of Medicine, and Division of Cardiac Surgery, (Meyer) Department of Surgery, Faculty of Medicine & Dentistry, University of Alberta, Edmonton, Alta
| | - Darryl Rolfson
- Department of Critical Care Medicine (Montgomery, Zibdawi, Bagshaw), Faculty of Medicine & Dentistry, University of Alberta, Edmonton, Alta.; Department of Critical Care Medicine (Stelfox), Cumming School of Medicine, and Department of Community Health Sciences (Stelfox), University of Calgary, Calgary, Alta.; Faculty of Nursing and School of Public Health (Norris, Bagshaw), University of Alberta; Strategic Clinical Networks (Norris, Bagshaw), Alberta Health Services; Division of Geriatric Medicine (Rolfson), Department of Medicine, and Division of Cardiac Surgery, (Meyer) Department of Surgery, Faculty of Medicine & Dentistry, University of Alberta, Edmonton, Alta
| | - Steven Meyer
- Department of Critical Care Medicine (Montgomery, Zibdawi, Bagshaw), Faculty of Medicine & Dentistry, University of Alberta, Edmonton, Alta.; Department of Critical Care Medicine (Stelfox), Cumming School of Medicine, and Department of Community Health Sciences (Stelfox), University of Calgary, Calgary, Alta.; Faculty of Nursing and School of Public Health (Norris, Bagshaw), University of Alberta; Strategic Clinical Networks (Norris, Bagshaw), Alberta Health Services; Division of Geriatric Medicine (Rolfson), Department of Medicine, and Division of Cardiac Surgery, (Meyer) Department of Surgery, Faculty of Medicine & Dentistry, University of Alberta, Edmonton, Alta
| | - Mohamad Zibdawi
- Department of Critical Care Medicine (Montgomery, Zibdawi, Bagshaw), Faculty of Medicine & Dentistry, University of Alberta, Edmonton, Alta.; Department of Critical Care Medicine (Stelfox), Cumming School of Medicine, and Department of Community Health Sciences (Stelfox), University of Calgary, Calgary, Alta.; Faculty of Nursing and School of Public Health (Norris, Bagshaw), University of Alberta; Strategic Clinical Networks (Norris, Bagshaw), Alberta Health Services; Division of Geriatric Medicine (Rolfson), Department of Medicine, and Division of Cardiac Surgery, (Meyer) Department of Surgery, Faculty of Medicine & Dentistry, University of Alberta, Edmonton, Alta
| | - Sean Bagshaw
- Department of Critical Care Medicine (Montgomery, Zibdawi, Bagshaw), Faculty of Medicine & Dentistry, University of Alberta, Edmonton, Alta.; Department of Critical Care Medicine (Stelfox), Cumming School of Medicine, and Department of Community Health Sciences (Stelfox), University of Calgary, Calgary, Alta.; Faculty of Nursing and School of Public Health (Norris, Bagshaw), University of Alberta; Strategic Clinical Networks (Norris, Bagshaw), Alberta Health Services; Division of Geriatric Medicine (Rolfson), Department of Medicine, and Division of Cardiac Surgery, (Meyer) Department of Surgery, Faculty of Medicine & Dentistry, University of Alberta, Edmonton, Alta
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Özsürekci C, Balcı C, Kızılarslanoğlu MC, Çalışkan H, Tuna Doğrul R, Ayçiçek GŞ, Sümer F, Karabulut E, Yavuz BB, Cankurtaran M, Halil MG. An important problem in an aging country: identifying the frailty via 9 Point Clinical Frailty Scale. Acta Clin Belg 2020; 75:200-204. [PMID: 30919742 DOI: 10.1080/17843286.2019.1597457] [Citation(s) in RCA: 25] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Abstract
OBJECTIVES Frailty is a geriatric syndrome which develops as a result of cumulative decline in many physiological systems and results in an increased vulnerability and risk of adverse outcomes. The Clinical Frailty Scale (CFS) was validated as a predictor of adverse outcomes in community-dwelling older people and evaluates items such as comorbidity, cognitive impairment and disability. We aimed to study the concurrent and construct validity and reliability of the 9 point CFS in Turkish Population.Methods: This study was designed as a cross-sectional study. Participants, who were admitted to a geriatric medicine outpatient clinic, were included. Validity of 9 point CFS was tested by its correlation with the assessment and opinion of an experienced geriatric medicine specialist and Fried frailty phenotype. Test-retest and inter-rater reliability analyses were also performed.Results: Median age of the 118 patients was 74.5 years (min: 65 max: 88) and 64.4 % were female. The concordance of CFS and experienced geriatric medicine specialist's opinion was excellent (Cohen's K: 0.80, p < 0.001).The concordance of CFS and Fried Frailty phenotype was moderate (Cohen's K: 0.514, p < 0.001).CFS inter-rater reliability and test-retest reliability was very strong (Cohen's K: 0.811, p < 0.001 and Cohen's K: 1.0, p < 0.001, respectively).Conclusions: CFS appears to be a quick, reliable and valid frailty screening tool for community-dwelling older adults in the Turkish population.
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Affiliation(s)
- Cemile Özsürekci
- Faculty of Medicine, Department of Internal Medicine Division of Geriatrics, Hacettepe University, Ankara, Turkey
| | - Cafer Balcı
- Faculty of Medicine, Department of Internal Medicine Division of Geriatrics, Hacettepe University, Ankara, Turkey
| | - M. Cemal Kızılarslanoğlu
- Faculty of Medicine, Department of Internal Medicine Division of Geriatrics, Gazi University, Ankara, Turkey
| | - Hatice Çalışkan
- Faculty of Medicine, Department of Internal Medicine Division of Geriatrics, Hacettepe University, Ankara, Turkey
| | - Rana Tuna Doğrul
- Faculty of Medicine, Department of Internal Medicine Division of Geriatrics, Hacettepe University, Ankara, Turkey
| | - Gözde Şengül Ayçiçek
- Faculty of Medicine, Department of Internal Medicine Division of Geriatrics, Hacettepe University, Ankara, Turkey
| | - Fatih Sümer
- Faculty of Medicine, Department of Internal Medicine Division of Geriatrics, Hacettepe University, Ankara, Turkey
| | - Erdem Karabulut
- Faculty of Medicine, Department of Biostatistics, Hacettepe University, Ankara, Turkey
| | - Burcu Balam Yavuz
- Faculty of Medicine, Department of Internal Medicine Division of Geriatrics, Hacettepe University, Ankara, Turkey
| | - Mustafa Cankurtaran
- Faculty of Medicine, Department of Internal Medicine Division of Geriatrics, Hacettepe University, Ankara, Turkey
| | - Meltem Gülhan Halil
- Faculty of Medicine, Department of Internal Medicine Division of Geriatrics, Hacettepe University, Ankara, Turkey
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Critical reflections on the blind sides of frailty in later life. J Aging Stud 2019; 49:66-73. [PMID: 31229220 DOI: 10.1016/j.jaging.2019.100787] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/22/2018] [Revised: 05/21/2019] [Accepted: 05/28/2019] [Indexed: 12/25/2022]
Abstract
Since the 1970's, frailty emerged as a major theme and has become one of the most researched topics in aging studies. However, throughout the years, the concept 'frailty' became susceptible to different interpretations and has been approached by different synonyms, which resulted in a confusing picture. Based on a narrative literature review, this theoretical paper not only attempts to describe these different views on frailty, but by criticizing the dominance of some of these views, it also aspires to move the research and policy agenda on frailty forward. This paper is part of the D-SCOPE project in Belgium, and critically reflects on the blind sides of the biomedical domination of frailty and discusses three main themes: 1) frailty as a multidimensional and multilevel concept; 2) positive perspectives on frailty in later life; and 3) the suggestion of moving from a merely deficit-based frailty approach towards the concept of frailty-balance. At the theoretical level, conceptualizing frailty is not simply an exercise in semantics, but altering the theoretical definition of frailty can have wide-ranging implications, not only for the way frailty prevalence is measured and handled, but also for public or personal opinions on frailty in older people, for care and support practices, and for the scope of legislation. Therefore, the final section of the paper presents three building blocks for future research and policy-making: 1) adopting a multidimensional, multilevel, dynamic and positive view on frailty; 2) moving from dependency to interdependency; and 3) giving voice to (the resilience of) frail older people.
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