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Moras E, Zaid S, Gandhi K, Barman N, Birnbaum Y, Virani SS, Tamis-Holland J, Jneid H, Krittanawong C. Pharmacotherapy for Coronary Artery Disease and Acute Coronary Syndrome in the Aging Population. Curr Atheroscler Rep 2024; 26:231-248. [PMID: 38722473 DOI: 10.1007/s11883-024-01203-9] [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] [Accepted: 04/19/2024] [Indexed: 06/22/2024]
Abstract
PURPOSE OF REVIEW To provide a comprehensive summary of relevant studies and evidence concerning the utilization of different pharmacotherapeutic and revascularization strategies in managing coronary artery disease and acute coronary syndrome specifically in the older adult population. RECENT FINDINGS Approximately 30% to 40% of hospitalized patients with acute coronary syndrome are older adults, among whom the majority of cardiovascular-related deaths occur. When compared to younger patients, these individuals generally experience inferior clinical outcomes. Most clinical trials assessing the efficacy and safety of various therapeutics have primarily enrolled patients under the age of 75, in addition to excluding those with geriatric complexities. In this review, we emphasize the need for a personalized and comprehensive approach to pharmacotherapy for coronary heart disease and acute coronary syndrome in older adults, considering concomitant geriatric syndromes and age-related factors to optimize treatment outcomes while minimizing potential risks and complications. In the realm of clinical practice, cardiovascular and geriatric risks are closely intertwined, with both being significant factors in determining treatments aimed at reducing negative outcomes and attaining health conditions most valued by older adults.
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Affiliation(s)
- Errol Moras
- Department of Internal Medicine, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Syed Zaid
- Section of Cardiology, Baylor College of Medicine, Houston, TX, USA
| | - Kruti Gandhi
- Department of Internal Medicine, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Nitin Barman
- Cardiac Catheterization Laboratory, Mount Sinai Morningside Hospital, New York, NY, USA
| | - Yochai Birnbaum
- Section of Cardiology, Baylor College of Medicine, Houston, TX, USA
| | | | | | - Hani Jneid
- Division of Cardiology, University of Texas Medical Branch, Houston, TX, USA
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Ansari H, Fung K, Cheung AM, Jaglal S, Bogoch ER, Kurdyak PA. Outcomes following hip fracture surgery in adults with schizophrenia in Ontario, Canada: A 10-year population-based retrospective cohort study. Gen Hosp Psychiatry 2024; 89:60-68. [PMID: 38797059 DOI: 10.1016/j.genhosppsych.2024.05.010] [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: 01/03/2024] [Revised: 04/02/2024] [Accepted: 05/17/2024] [Indexed: 05/29/2024]
Abstract
OBJECTIVE To understand immediate and long-term outcomes following hip fracture surgery in adults with schizophrenia. METHODS Retrospective population-based cohort study leveraging health administrative databases from Ontario, Canada. Individuals aged 40-105 years with hip fracture surgery between April 1, 2009 and March 31, 2019 were included. Schizophrenia was ascertained using a validated algorithm. Outcomes were: 30-day mortality; 30-day readmission; 1-year survival; and subsequent hip fracture within 2 years. Analyses incorporated Generalized Estimating Equation models, Kaplan-Meier curves, and Fine-Gray competing risk models. RESULTS In this cohort study of 98,126 surgically managed hip fracture patients, the median [IQR] age was 83[75-89] years, 69.2% were women, and 3700(3.8%) had schizophrenia. In Fine-Gray models, schizophrenia was associated with subsequent hip fracture (sdRH, 1.29; 95% CI, 1.09-1.53), with male patients with schizophrenia sustaining a refracture 50 days earlier. In age- and sex-adjusted GEE models, schizophrenia was associated with 30-day mortality (OR, 1.31; 95% CI, 1.12-1.54) and readmissions (OR, 1.40; 95% CI, 1.25-1.56). Kaplan-Meier survival curves suggested that patients with schizophrenia were less likely to be alive at 1-year. CONCLUSIONS Study highlights the susceptibility of hip fracture patients with schizophrenia to worse outcomes, including refracture, with implications for understanding modifiable processes of care to optimize their recovery.
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Affiliation(s)
- Hina Ansari
- Institute of Health Policy, Management and Evaluation, Dalla Lana School of Public Health, University of Toronto, Toronto, Ontario, Canada.
| | | | - Angela M Cheung
- Department of Medicine and Joint Department of Medical Imaging, University Health Network and Sinai Health System, University of Toronto, Toronto, Ontario, Canada
| | - Susan Jaglal
- ICES, Toronto, Ontario, Canada; Toronto Rehabilitation Institute, University Health Network, Toronto, Ontario, Canada; Department of Physical Therapy, University of Toronto, Toronto, Ontario, Canada
| | - Earl R Bogoch
- Brookfield Chair in Fracture Prevention, St. Michael's Hospital, Unity Health Toronto, Toronto, Ontario, Canada; Department of Surgery, University of Toronto, Toronto, Ontario, Canada; Li Ka Shing Knowledge Institute of St. Michael's Hospital, Unity Health Toronto, Toronto, Ontario, Canada
| | - Paul A Kurdyak
- Institute of Health Policy, Management and Evaluation, Dalla Lana School of Public Health, University of Toronto, Toronto, Ontario, Canada; ICES, Toronto, Ontario, Canada; Department of Psychiatry, Temerty Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada; Centre for Addiction and Mental Health, Toronto, Ontario, Canada
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Ansari H, Jaglal S, Cheung AM, Jain R, Weldon J, Kurdyak P. Osteoporosis management in adults with schizophrenia following index hip fracture event: a 10-year population-based retrospective cohort study, Ontario, Canada. Osteoporos Int 2024; 35:1289-1298. [PMID: 38760503 DOI: 10.1007/s00198-024-07123-3] [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: 09/27/2023] [Accepted: 05/08/2024] [Indexed: 05/19/2024]
Abstract
Little is known about the incidence of osteoporosis testing and treatment in individuals with schizophrenia, who may be more likely to fracture. Using competing risk models, we found that schizophrenia was associated with lower incidence of testing or treatment. Implications are for understanding barriers and solutions for this disadvantaged group. PURPOSE Evidence suggests that individuals with schizophrenia may be more likely to experience hip fractures than the general population; however, little is known about osteoporosis management in this disadvantaged subpopulation. Our study objective was to compare bone mineral density (BMD) testing and pharmacologic treatment in hip fracture patients with versus without schizophrenia. METHODS This was a retrospective population-based cohort study leveraging health administrative databases, and individuals aged 66-105 years with hip fracture between fiscal years 2009 and 2018 in Ontario, Canada. Schizophrenia was ascertained using a validated algorithm. The outcome was a composite measure of (1) pharmacologic prescription for osteoporosis; or (2) a BMD test. Inferential analyses were conducted using Fine-Gray subdistribution hazard regression, with mortality as the competing event. RESULTS A total of 52,722 individuals aged 66 to 105 years who sustained an index hip fracture in Ontario during the study period were identified, of whom 1890 (3.6%) had schizophrenia. Hip fracture patients with vs without schizophrenia were more likely to be long-term care residents (44.3% vs. 18.1%; standardized difference, 0.59), frail (62.5% vs. 36.5%; standardized difference, 0.54) and without a primary care provider (9.2% vs. 4.8%; standardized difference, 0.18). In Fine-Gray models, schizophrenia was associated with a lower incidence of testing or treatment (0.795 (0.721, 0.877)). CONCLUSIONS In this population-based retrospective cohort study, a schizophrenia diagnosis among hip fracture patients was associated with a lower incidence of testing or treatment, after accounting for mortality, and several enabling and predisposing factors. Further research is required to investigate barriers to osteoporosis management in this disadvantaged population.
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Affiliation(s)
- H Ansari
- Institute of Health Policy, Management and Evaluation, Dalla Lana School of Public Health, University of Toronto, Toronto, ON, Canada.
| | - S Jaglal
- ICES, Toronto, ON, Canada
- Toronto Rehabilitation Institute, University Health Network, Toronto, ON, Canada
- Department of Physical Therapy, University of Toronto, Toronto, ON, Canada
| | - A M Cheung
- Department of Medicine and Joint Department of Medical Imaging, University Health Network and Sinai Health System, University of Toronto, Toronto, ON, Canada
| | - R Jain
- Ontario Osteoporosis Strategy, Osteoporosis Canada, Toronto, ON, Canada
| | - J Weldon
- Ontario Osteoporosis Strategy, Osteoporosis Canada, Toronto, ON, Canada
| | - P Kurdyak
- Institute of Health Policy, Management and Evaluation, Dalla Lana School of Public Health, University of Toronto, Toronto, ON, Canada
- ICES, Toronto, ON, Canada
- Department of Psychiatry, Temerty Faculty of Medicine, University of Toronto, Toronto, ON, Canada
- Centre for Addiction and Mental Health, Toronto, ON, Canada
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Rubens FD, Fremes SE, Grubic N, Fergusson D, Taljaard M, van Walraven C. Outcomes following coronary artery bypass grafting with multiple arterial grafting by pump status in men and women. J Thorac Cardiovasc Surg 2024; 167:1796-1807.e15. [PMID: 36935299 DOI: 10.1016/j.jtcvs.2023.02.008] [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: 10/23/2022] [Revised: 01/17/2023] [Accepted: 02/04/2023] [Indexed: 02/17/2023]
Abstract
BACKGROUND Multiple arterial grafting (MAG) and off-pump surgery are strategies proposed to improve outcomes with coronary artery bypass grafting (CABG). This study was conducted to determine the impact of off-pump surgery on outcomes after CABG with MAG in men and women. METHODS This cohort study used population-based data to identify all Ontarians undergoing isolated CABG with MAG between October 2008 and September 2019. The primary outcome was all-cause mortality. Secondary outcomes included major adverse cardiac and cerebrovascular events (MACCE; hospitalization for stroke, myocardial infarction hospitalization or heart failure, or repeat revascularization). Analysis used propensity-score overlap-weighted cause-specific Cox proportional hazard regression. RESULTS A total of 2989 women (1188 off-pump, 1801 on-pump) and 16,209 men (6065 off-pump, 10,144 on-pump) underwent MAG with a median follow-up of 5.0 years (interquartile range, 2.7-8.0) years. Compared to the on-pump approach, all-cause mortality was not changed with off-pump status (hazard ratio [HR] in women: 1.25 [95% CI, 0.83-1.88]; in men: 1.08 [95% CI, 0.85-1.37]). In women, the risk of MACCE was significantly higher off-pump (HR, 1.45; 95% CI, 1.04-2.03), with nonsignificantly increased risk observed for all component outcomes. CONCLUSIONS In patients undergoing CABG with MAG, this population-based analysis found no association between pump status and survival in either men or women. However, it did suggest that off-pump MAG in women may be associated with an increased risk of MACCE.
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Affiliation(s)
- Fraser D Rubens
- Division of Cardiac Surgery, University of Ottawa Heart Institute, Ottawa, Ontario, Canada; School of Epidemiology and Public Health, University of Ottawa, Ottawa, Ontario, Canada.
| | - Stephen E Fremes
- Division of Cardiac Surgery, Department of Surgery, Schulich Heart Centre, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, Ontario, Canada
| | - Nicholas Grubic
- ICES (formerly Institute for Clinical Evaluative Sciences), Toronto, Ontario, Canada; Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
| | - Dean Fergusson
- School of Epidemiology and Public Health, University of Ottawa, Ottawa, Ontario, Canada; Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
| | - Monica Taljaard
- School of Epidemiology and Public Health, University of Ottawa, Ottawa, Ontario, Canada; Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
| | - Carl van Walraven
- School of Epidemiology and Public Health, University of Ottawa, Ottawa, Ontario, Canada; ICES (formerly Institute for Clinical Evaluative Sciences), Toronto, Ontario, Canada; Ottawa Hospital Research Institute, Ottawa, Ontario, Canada; Department of Medicine, University of Ottawa, Ottawa, Ontario, Canada
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Etherington C, Boet S, Chen I, Duffy M, Mamas MA, Bader Eddeen A, Bateman BT, Sun LY. Association Between Surgeon/Anesthesiologist Sex Discordance and 1-year Mortality Among Adults Undergoing Noncardiac Surgery: A Population-based Retrospective Cohort Study. Ann Surg 2024; 279:563-568. [PMID: 37791498 DOI: 10.1097/sla.0000000000006111] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/05/2023]
Abstract
OBJECTIVE To investigate the association between surgeon-anesthesiologist sex discordance and patient mortality after noncardiac surgery. BACKGROUND Evidence suggests different practice patterns exist among female and male physicians. However, the influence of physician sex on team-based practices in the operating room and subsequent patient outcomes remains unclear in the context of noncardiac surgery. METHODS We conducted a population-based, retrospective cohort study of adult Ontario residents who underwent index, inpatient noncardiac surgery between January 2007 and December 2017. The primary exposure was physician sex discordance (ie, the surgeon and anesthesiologist were of the opposite sex). The primary outcome was 1-year mortality. The association between physician sex discordance and patient outcomes was modeled using multivariable Cox proportional hazard regression with adjustment for relevant physician, patient, and hospital characteristics. RESULTS Of 541,209 patients, 158,084 (29.2%) were treated by sex-discordant physician teams. Physician sex discordance was associated with a lower rate of mortality at 1 year [5.2% vs. 5.7%; adjusted HR: 0.95 (0.91-0.99)]. Patients treated by teams composed of female surgeons and male anesthesiologists were more likely to be alive at 1 year than those treated by all-male physician teams [adjusted HR: 0.90 (0.81-0.99)]. CONCLUSIONS Noncardiac surgery patients had a lower likelihood of 1-year mortality when treated by sex-discordant surgeon-anesthesiologist teams. The likelihood of mortality was further reduced if the surgeon was female. Further research is needed to explore the underlying mechanisms of these observations and design strategies to diversify operating room teams to optimize performance and patient outcomes.
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Affiliation(s)
- Cole Etherington
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, ON, Canada
- Department of Anesthesiology and Pain Medicine, Faculty of Medicine, University of Ottawa, Ottawa, ON, Canada
| | - Sylvain Boet
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, ON, Canada
- Department of Anesthesiology and Pain Medicine, Faculty of Medicine, University of Ottawa, Ottawa, ON, Canada
| | - Innie Chen
- Department of Obstetrics and Gynecology, Faculty of Medicine, University of Ottawa, Ottawa, ON, Canada
| | - Melissa Duffy
- Department of Educational Studies, University of South Carolina, Columbia, SC
| | - Mamas A Mamas
- Keele Cardiovascular Research Group, Centre for Prognosis Research, Keele University, Keele, Staffordshire, UK
| | | | - Brian T Bateman
- Department of Anesthesiology, Perioperative and Pain Medicine, Stanford University School of Medicine, Stanford, CA
| | - Louise Y Sun
- Institute for Clinical Evaluative Sciences, ON, Canada
- Department of Anesthesiology, Perioperative and Pain Medicine, Stanford University School of Medicine, Stanford, CA
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Niebauer J, Bäck C, Bischoff-Ferrari HA, Dehbi HM, Szekely A, Völler H, Sündermann SH. Preinterventional frailty assessment in patients scheduled for cardiac surgery or transcatheter aortic valve implantation: a consensus statement of the European Association for Cardio-Thoracic Surgery (EACTS) and the European Association of Preventive Cardiology (EAPC) of the European Society of Cardiology (ESC). Eur J Prev Cardiol 2024; 31:146-181. [PMID: 37804173 DOI: 10.1093/eurjpc/zwad304] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/10/2022] [Revised: 03/22/2023] [Indexed: 10/09/2023]
Affiliation(s)
- Josef Niebauer
- Paracelsus Medical University Salzburg, Institute of Sports Medicine, Prevention and Rehabilitation, Salzburg, Austria
- Ludwig Boltzmann Institute for Digital Health and Prevention, Salzburg, Austria
- REHA-Zentrum Salzburg, University Hospital Salzburg, Austria
| | - Caroline Bäck
- Department of Cardiothoracic Surgery, RT, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark
| | - Heike A Bischoff-Ferrari
- Center on Ageing and Mobility, University Hospital and University of Zurich, Zurich, Switzerland
| | - Hakim-Moulay Dehbi
- University College London, Comprehensive Clinical Trials Unit, London, Great Britain
| | - Andrea Szekely
- Semmelweis University, Department of Anesthesiology and Intensive Therapy, Budapest, Hungary
| | - Heinz Völler
- Faculty of Health Sciences Brandenburg, University of Potsdam, Department of Rehabilitation Medicine, Potsdam, Germany
- Klinik am See, Rehabilitation Centre for Internal Medicine, Rüdersdorf, Germany
| | - Simon H Sündermann
- Deutsches Herzzentrum der Charité, Department of Cardiothoracic and Vascular Surgery, Berlin, Germany
- Charité- Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt Universität zu Berlin, Berlin, Germany
- DZHK (German Center of Cardiovascular Research), Partner Site Berlin, Berlin, Germany
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Percy ED, Faggion Vinholo T, Newell P, Singh S, Hirji S, Awtry J, Semco R, Chowdhury M, Reed AK, Asokan S, Malarczyk A, Okoh A, Harloff M, Yazdchi F, Kaneko T, Sabe AA. The Impact of Frailty on Outcomes of Proximal Aortic Aneurysm Surgery: A Nationwide Analysis. J Cardiovasc Dev Dis 2024; 11:32. [PMID: 38276658 PMCID: PMC10816774 DOI: 10.3390/jcdd11010032] [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: 12/19/2023] [Revised: 01/16/2024] [Accepted: 01/18/2024] [Indexed: 01/27/2024] Open
Abstract
(1) Background: This study examines frailty's impact on proximal aortic surgery outcomes. (2) Methods: All patients with a thoracic aortic aneurysm who underwent aortic root, ascending aorta, or arch surgery from the 2016-2017 National Inpatient Sample were included. Frailty was defined by the Adjusted Clinical Groups Frailty Indicator. Outcomes of interest included in-hospital mortality and a composite of death, stroke, acute kidney injury (AKI), and major bleeding (MACE). (3) Results: Among 5745 patients, 405 (7.0%) met frailty criteria. Frail patients were older, with higher rates of chronic pulmonary disease, diabetes, and chronic kidney disease. There was no difference in in-hospital death (4.9% vs. 2.4%, p = 0.169); however, the frail group exhibited higher rates of stroke and AKI. Frail patients had a longer length of stay (17 vs. 8 days), and higher rates of non-home discharge (74.1% vs. 54.3%) than non-frail patients (both p < 0.001). Sensitivity analysis confirmed increased morbidity and mortality in frail individuals. After adjusting for patient comorbidities and hospital characteristics, frailty independently predicted MACE (OR 4.29 [1.88-9.78], p = 0.001), while age alone did not (OR 1.00 [0.99-1.02], p = 0.568). Urban teaching center status predicted a lower risk of MACE (OR 0.27 [0.08-0.94], p = 0.039). (4) Conclusions: Frailty is associated with increased morbidity in proximal aortic surgery and is a more significant predictor of mortality than age. Coordinated treatment in urban institutions may enhance outcomes for this high-risk group.
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Affiliation(s)
- Edward D. Percy
- Division of Cardiac Surgery, Department of Surgery, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA 02115, USA
- Division of Cardiovascular Surgery, University of Pennsylvania Medical Center, Philadelphia, PA 19104, USA
| | - Thais Faggion Vinholo
- Division of Cardiac Surgery, Department of Surgery, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA 02115, USA
- Division of Cardiovascular Surgery, University of Pennsylvania Medical Center, Philadelphia, PA 19104, USA
| | - Paige Newell
- Division of Cardiac Surgery, Department of Surgery, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA 02115, USA
| | - Supreet Singh
- Department of Internal Medicine, Mount Sinai Hospital, New York, NY 10029, USA
| | - Sameer Hirji
- Division of Cardiac Surgery, Department of Surgery, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA 02115, USA
| | - Jake Awtry
- Division of Cardiac Surgery, Department of Surgery, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA 02115, USA
| | - Robert Semco
- Division of Cardiac Surgery, Department of Surgery, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA 02115, USA
| | - Muntasir Chowdhury
- Department of Internal Medicine, Trinity Health System, Steubenville, OH 43952, USA
| | - Alexander K. Reed
- Department of Cardiothoracic Surgery, Stanford University, Stanford, CA 94304, USA
| | - Sainath Asokan
- Department of Pediatrics, St. Christopher’s Hospital for Children, Philadelphia, PA 19134, USA
| | - Alexandra Malarczyk
- Division of Cardiac Surgery, Department of Surgery, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA 02115, USA
| | - Alexis Okoh
- Division of Cardiology, Emory University School of Medicine, Atlanta, GA 30322, USA
| | - Morgan Harloff
- Division of Cardiac Surgery, Department of Surgery, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA 02115, USA
| | - Farhang Yazdchi
- Division of Cardiac Surgery, University of Michigan, Ann Arbor, MI 48109, USA
| | - Tsuyoshi Kaneko
- Division of Cardiothoracic Surgery, Barnes-Jewish Hospital, Washington University in St Louis, St. Louis, MO 63110, USA
| | - Ashraf A. Sabe
- Division of Cardiac Surgery, Department of Surgery, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA 02115, USA
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Farmakis IT, Barco S, Giannakoulas G, Keller K, Valerio L, Tichelbäcker T, Partovi S, Ahrens I, Konstantinides SV, Hobohm L. A nationwide analysis of reperfusion therapies for pulmonary embolism in older patients with frailty. EUROINTERVENTION 2023; 19:772-781. [PMID: 37767997 PMCID: PMC10654770 DOI: 10.4244/eij-d-23-00399] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/22/2023] [Accepted: 08/15/2023] [Indexed: 09/29/2023]
Abstract
BACKGROUND Reperfusion therapy is challenging in the elderly. Catheter-directed therapies are an alternative for higher-risk pulmonary embolism (PE) patients if systemic thrombolysis (ST) is contraindicated or has failed. Their safety has not been evaluated in specific vulnerable populations. AIMS We aimed to assess the safety of reperfusion therapies in elderly and frail patients in the real world. METHODS In the US Nationwide Inpatient Sample from 2016 to 2020, we identified hospitalisations of patients ≥65 years with PE and defined a frailty subgroup using the Johns Hopkins Adjusted Clinical Groups frailty-defining diagnosis indicator. We investigated reperfusion therapies (ST, catheter-directed thrombolysis [CDT], catheter-based thrombectomy [CBT], surgical embolectomy [SE]) and their associated safety outcomes (overall and major bleeding). RESULTS Among 980,245 hospitalisations of patients ≥65 years with PE (28.0% frail), reperfusion therapies were used in 4.9% (17.6% among high-risk PE). ST utilisation remained stable, while the use of catheter-directed therapies increased from 1.7% in 2016 to 3.2% in 2020. Among all hospitalisations with reperfusion, CDT, compared to ST, was associated with reduced major bleeding (5.8% vs 12.2%, odds ratio [OR] 0.58, 95% confidence interval [CI]: 0.49-0.70); these results also applied to frail patients. CBT, compared to SE, was also associated with reduced major bleeding (11.0% vs 22.4%, OR 0.63, 95% CI: 0.43-0.91), but not among frail patients. These differences were particularly significant in patients with non-high-risk PE. Differences persisted for overall bleeding as well. CONCLUSIONS Catheter-directed therapies may be a safer alternative to classical reperfusion therapies for elderly and frail patients with PE requiring reperfusion treatment.
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Affiliation(s)
- Ioannis T Farmakis
- Center for Thrombosis and Hemostasis, University Medical Center of the Johannes Gutenberg University, Mainz, Germany
| | - Stefano Barco
- Center for Thrombosis and Hemostasis, University Medical Center of the Johannes Gutenberg University, Mainz, Germany
- Department of Angiology, University Hospital Zurich, Zurich, Switzerland
| | - George Giannakoulas
- Department of Cardiology, AHEPA University General Hospital of Thessaloniki, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - Karsten Keller
- Center for Thrombosis and Hemostasis, University Medical Center of the Johannes Gutenberg University, Mainz, Germany
- Department of Cardiology, University Medical Center of the Johannes Gutenberg University, Mainz, Germany
- Medical Clinic VII, Department of Sports Medicine, University Hospital Heidelberg, Heidelberg, Germany
| | - Luca Valerio
- Center for Thrombosis and Hemostasis, University Medical Center of the Johannes Gutenberg University, Mainz, Germany
- Department of Cardiology, University Medical Center of the Johannes Gutenberg University, Mainz, Germany
| | - Tobias Tichelbäcker
- Clinic III for Internal Medicine, Heart Centre of University Hospital of Cologne, Cologne, Germany
| | - Sasan Partovi
- Interventional Radiology Section, Imaging Institute, Cleveland Clinic Main Campus, Cleveland, OH, USA
| | - Ingo Ahrens
- Department of Cardiology and Medical Intensive Care, Augustinerinnen Hospital, Academic Teaching Hospital University of Cologne, Cologne, Germany
| | - Stavros V Konstantinides
- Center for Thrombosis and Hemostasis, University Medical Center of the Johannes Gutenberg University, Mainz, Germany
- Department of Cardiology, Democritus University of Thrace, Alexandroupolis, Greece
| | - Lukas Hobohm
- Center for Thrombosis and Hemostasis, University Medical Center of the Johannes Gutenberg University, Mainz, Germany
- Department of Cardiology, University Medical Center of the Johannes Gutenberg University, Mainz, Germany
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Bayer N, Schmoeckel M, Wohlmuth P, Geidel S. Impact of Graft Strategies on the Outcome of Octogenarians Undergoing Coronary Artery Bypass Grafting. Ann Thorac Cardiovasc Surg 2023; 29:241-248. [PMID: 36990786 PMCID: PMC10587474 DOI: 10.5761/atcs.oa.22-00193] [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: 10/17/2022] [Accepted: 02/26/2023] [Indexed: 03/30/2023] Open
Abstract
PURPOSE To analyse the outcome of coronary artery bypass grafting (CABG) in octogenarians with coronary multivessel disease and the impact of different graft strategies and other factors. METHODS Out of 1654 patients with multivessel disease who underwent CABG at our institution between January 2014 and March 2020, we investigated 225 consecutive patients with a median age of 82.1 years for survival prediction and need for coronary reintervention; a detailed outcome analysis was performed. RESULTS At mean follow-up of 3.3 years, the overall survival was 76.4%. An indication for emergency operation (p = 0.002), age (p <0.001), chronic pulmonary disease (p = 0.024), and reduced renal or ventricular function (p <0.001) had the highest impact on limited survival. The combination outcome of survival and coronary reintervention was 1.7-fold improved (p = 0.024) after use of the bilateral internal thoracic artery (BITA) (66.2%). Off-pump CABG (12%) revealed no impact on survival. Smokers showed a poorer outcome (p = 0.004). The logistic European System for Cardiac Operative Risk Evaluation was highly effective for evaluating long-term outcomes (p <0.001). CONCLUSIONS BITA grafting normalizes survival and reveals a better outcome in octogenarians with multivessel disease. However, patients at risk of poorer survival were operated under emergency conditions and those with pulmonary disease and reduced ventricular or renal function.
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Affiliation(s)
- Nicolai Bayer
- Department of Cardiac Surgery, Asklepios Klinik St. Georg, Hamburg, Germany
| | - Michael Schmoeckel
- Department of Cardiac Surgery, Asklepios Klinik St. Georg, Hamburg, Germany
| | | | - Stephan Geidel
- Department of Cardiac Surgery, Asklepios Klinik St. Georg, Hamburg, Germany
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10
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Sündermann SH, Bäck C, Bischoff-Ferrari HA, Dehbi HM, Szekely A, Völler H, Niebauer J. Preinterventional frailty assessment in patients scheduled for cardiac surgery or transcatheter aortic valve implantation: a consensus statement of the European Association for Cardio-Thoracic Surgery (EACTS) and the European Association of Preventive Cardiology (EAPC) of the European Society of Cardiology (ESC). Eur J Cardiothorac Surg 2023; 64:ezad181. [PMID: 37804175 DOI: 10.1093/ejcts/ezad181] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/10/2022] [Revised: 03/22/2023] [Indexed: 10/09/2023] Open
Affiliation(s)
- Simon H Sündermann
- Deutsches Herzzentrum der Charité, Department of Cardiothoracic and Vascular Surgery, Berlin, Germany
- Charité- Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt Universität zu Berlin, Berlin, Germany
- DZHK (German Center of Cardiovascular Research), Partner Site Berlin, Berlin, Germany
| | - Caroline Bäck
- Department of Cardiothoracic Surgery, RT, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark
| | - Heike A Bischoff-Ferrari
- Center on Ageing and Mobility, University Hospital and University of Zurich, Zurich, Switzerland
| | - Hakim-Moulay Dehbi
- University College London, Comprehensive Clinical Trials Unit, London, Great Britain
| | - Andrea Szekely
- Semmelweis University, Department of Anesthesiology and Intensive Therapy, Budapest, Hungary
| | - Heinz Völler
- Faculty of Health Sciences Brandenburg, University of Potsdam, Department of Rehabilitation Medicine, Potsdam, Germany
- Klinik am See, Rehabilitation Centre for Internal Medicine, Rüdersdorf, Germany
| | - Josef Niebauer
- Paracelsus Medical University Salzburg, Institute of Sports Medicine, Prevention and Rehabilitation, Salzburg, Austria
- Ludwig Boltzmann Institute for Digital Health and Prevention, Salzburg, Austria
- REHA-Zentrum Salzburg, University Hospital Salzburg, Austria
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11
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Shahrestani S, Sayed S, Nasrollahi T, Nasrollahi T, Huang L, McGillivray E, Chour W, Foong A, Dowlatshahi S. Association between frailty status and complications in patients undergoing surgical excision of malignant esophageal neoplasms. Ann Gastroenterol 2023; 36:517-523. [PMID: 37664228 PMCID: PMC10433248 DOI: 10.20524/aog.2023.0825] [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: 01/25/2023] [Accepted: 06/30/2023] [Indexed: 09/05/2023] Open
Abstract
Background Research within the last decade highlights the patients' frailty status as an important predictor of esophageal cancer outcomes, but the literature evaluating frailty's role in these patients remains limited. We evaluated the role of frailty in patients undergoing resection of malignant esophageal neoplasms. Methods We used the Nationwide Readmissions Database from 2016 and 2017 to identify patients who underwent excision of a malignant esophageal neoplasm. Patient frailty was queried using the Johns Hopkins Adjusted Clinical Groups frailty-defining diagnosis indicator. Propensity score matching identified 289 frail patients and 281 non-frail patients. Mann-Whitney U testing was performed and receiver operating characteristic (ROC) curves were created, following the creation of logistic regression models for predicting discharge disposition. The area under the curve (AUC) served as a proxy for model performance. Results Frail patients had significantly more nonroutine discharges, longer inpatient lengths of stay, higher costs, more acute infections, posthemorrhagic anemia and deep vein thrombosis, and greater mortality (P<0.05). No significant differences were found between the 2 cohorts with respect to readmission rates, pulmonary embolism or dysphagia. Predictive models for patient discharge disposition demonstrated that frailty status in combination with age resulted in better ROC curves (AUC: 0.652) compared to models using age alone (AUC: 0.601). Conclusions Frailty was found to be significantly correlated with higher rates of inpatient medical complications following esophagectomy. The inclusion of patient frailty status in predictive models for discharge disposition resulted in a better predictive capacity compared to those using age alone.
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Affiliation(s)
- Shane Shahrestani
- Department of Internal Medicine, Keck School of Medicine, University of Southern California, Los Angeles (Shane Shahrestani, Sammy Sayed, Linda Huang, Erin McGillivray, William Chour, Andrew Foong, Shadi Dowlatshahi)
- Department of Medical Engineering, California Institute of Technology, Pasadena (Shane Shahrestani)
| | - Sammy Sayed
- Department of Internal Medicine, Keck School of Medicine, University of Southern California, Los Angeles (Shane Shahrestani, Sammy Sayed, Linda Huang, Erin McGillivray, William Chour, Andrew Foong, Shadi Dowlatshahi)
| | - Tania Nasrollahi
- California Northstate University College of Medicine, Elk Grove (Tania Nasrollahi, Tasha Nasrollahi), CA, USA
| | - Tasha Nasrollahi
- California Northstate University College of Medicine, Elk Grove (Tania Nasrollahi, Tasha Nasrollahi), CA, USA
| | - Linda Huang
- Department of Internal Medicine, Keck School of Medicine, University of Southern California, Los Angeles (Shane Shahrestani, Sammy Sayed, Linda Huang, Erin McGillivray, William Chour, Andrew Foong, Shadi Dowlatshahi)
| | - Erin McGillivray
- Department of Internal Medicine, Keck School of Medicine, University of Southern California, Los Angeles (Shane Shahrestani, Sammy Sayed, Linda Huang, Erin McGillivray, William Chour, Andrew Foong, Shadi Dowlatshahi)
| | - William Chour
- Department of Internal Medicine, Keck School of Medicine, University of Southern California, Los Angeles (Shane Shahrestani, Sammy Sayed, Linda Huang, Erin McGillivray, William Chour, Andrew Foong, Shadi Dowlatshahi)
| | - Andrew Foong
- Department of Internal Medicine, Keck School of Medicine, University of Southern California, Los Angeles (Shane Shahrestani, Sammy Sayed, Linda Huang, Erin McGillivray, William Chour, Andrew Foong, Shadi Dowlatshahi)
| | - Shadi Dowlatshahi
- Department of Internal Medicine, Keck School of Medicine, University of Southern California, Los Angeles (Shane Shahrestani, Sammy Sayed, Linda Huang, Erin McGillivray, William Chour, Andrew Foong, Shadi Dowlatshahi)
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12
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Virani SS, Newby LK, Arnold SV, Bittner V, Brewer LC, Demeter SH, Dixon DL, Fearon WF, Hess B, Johnson HM, Kazi DS, Kolte D, Kumbhani DJ, LoFaso J, Mahtta D, Mark DB, Minissian M, Navar AM, Patel AR, Piano MR, Rodriguez F, Talbot AW, Taqueti VR, Thomas RJ, van Diepen S, Wiggins B, Williams MS. 2023 AHA/ACC/ACCP/ASPC/NLA/PCNA Guideline for the Management of Patients With Chronic Coronary Disease: A Report of the American Heart Association/American College of Cardiology Joint Committee on Clinical Practice Guidelines. Circulation 2023; 148:e9-e119. [PMID: 37471501 DOI: 10.1161/cir.0000000000001168] [Citation(s) in RCA: 126] [Impact Index Per Article: 126.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 07/22/2023]
Abstract
AIM The "2023 AHA/ACC/ACCP/ASPC/NLA/PCNA Guideline for the Management of Patients With Chronic Coronary Disease" provides an update to and consolidates new evidence since the "2012 ACCF/AHA/ACP/AATS/PCNA/SCAI/STS Guideline for the Diagnosis and Management of Patients With Stable Ischemic Heart Disease" and the corresponding "2014 ACC/AHA/AATS/PCNA/SCAI/STS Focused Update of the Guideline for the Diagnosis and Management of Patients With Stable Ischemic Heart Disease." METHODS A comprehensive literature search was conducted from September 2021 to May 2022. Clinical studies, systematic reviews and meta-analyses, and other evidence conducted on human participants were identified that were published in English from MEDLINE (through PubMed), EMBASE, the Cochrane Library, Agency for Healthcare Research and Quality, and other selected databases relevant to this guideline. STRUCTURE This guideline provides an evidenced-based and patient-centered approach to management of patients with chronic coronary disease, considering social determinants of health and incorporating the principles of shared decision-making and team-based care. Relevant topics include general approaches to treatment decisions, guideline-directed management and therapy to reduce symptoms and future cardiovascular events, decision-making pertaining to revascularization in patients with chronic coronary disease, recommendations for management in special populations, patient follow-up and monitoring, evidence gaps, and areas in need of future research. Where applicable, and based on availability of cost-effectiveness data, cost-value recommendations are also provided for clinicians. Many recommendations from previously published guidelines have been updated with new evidence, and new recommendations have been created when supported by published data.
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Affiliation(s)
| | | | | | | | | | | | - Dave L Dixon
- Former Joint Committee on Clinical Practice Guideline member; current member during the writing effort
| | - William F Fearon
- Society for Cardiovascular Angiography and Interventions representative
| | | | | | | | - Dhaval Kolte
- AHA/ACC Joint Committee on Clinical Data Standards
| | | | | | | | - Daniel B Mark
- Former Joint Committee on Clinical Practice Guideline member; current member during the writing effort
| | | | | | | | - Mariann R Piano
- Former Joint Committee on Clinical Practice Guideline member; current member during the writing effort
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13
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Ansari H, Jaglal S, Cheung AM, Kurdyak P. Characterization of Hip Fractures Among Adults With Schizophrenia in Ontario, Canada. JAMA Netw Open 2023; 6:e2310550. [PMID: 37115547 PMCID: PMC10148203 DOI: 10.1001/jamanetworkopen.2023.10550] [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: 04/29/2023] Open
Abstract
Importance Evidence suggests that individuals with schizophrenia are at an increased risk of hip fractures; however, the sex-specific burden of hip fractures among adults with schizophrenia has not been quantified and compared with the general population. Objective To describe sociodemographic and clinical characteristics of patients with hip fracture and schizophrenia and to quantify their sex-specific annual hip fracture rates relative to those without schizophrenia. Design, Setting, and Participants This repeated population-based, cross-sectional study leveraged multiple individually linked health administrative databases for patients in Ontario, Canada. We included patients aged 40 to 105 years with hip fracture-related hospitalization between April 1, 2009, and March 31, 2019. Statistical analysis was performed between November 2021 and February 2023. Exposure Schizophrenia diagnosis, ascertained using a validated algorithm. Main Outcomes and Measures The main outcome was sex-specific age-standardized annual hip fracture rate per 10 000 individuals and annual percent change in age-standardized rates. Rates were direct adjusted to the 2011 Ontario population, and joinpoint regression analysis was performed to evaluate annual percent change. Results We identified 117 431 hip fracture records; of these, there were 109 908 index events. Among the 109 908 patients with hip fracture, 4251 had schizophrenia and 105 657 did not. Their median age was 83 years (IQR, 75-89 years), and 34 500 (31.4%) were men. Patients with hip fracture and schizophrenia were younger at the index event compared with those without schizophrenia. Men had a median age of 73 vs 81 years (IQR, 62-83 vs 71-87 years; standardized difference, 0.46), and women had a median age of 80 vs 84 years (IQR, 71-87 vs 77-89 years; standardized difference, 0.32). A higher proportion of patients with vs without schizophrenia had frailty (53.7% vs 34.2%; standardized difference, 0.40) and previous fragility fractures (23.5% vs 19.1%; standardized difference, 0.11). The overall age-standardized rate per 10 000 individuals with vs without schizophrenia was 37.5 (95% CI, 36.4 to 38.6) vs 16.0 (95% CI, 15.9 to 16.1). Age-standardized rates were 3-fold higher in men with vs without schizophrenia (31.0 [95% CI, 29.5 to 32.6] vs 10.1 [95% CI, 10.0 to 10.2]) and more than 2-fold higher in women with vs without schizophrenia (43.4 [95% CI, 41.9 to 44.9] vs 21.4 [95% CI, 21.3 to 21.6]). Overall, joinpoint regression analysis identified a steady annual decrease of 0.7% (95% CI, -1.1% to -0.3%) in age-standardized rates for both study groups. Conclusions and Relevance The findings of this cross-sectional study suggest that individuals with schizophrenia experience an earlier age of onset and considerably higher rate of hip fractures compared with the general population, with implications for targeted fracture prevention and optimization of clinical bone health management over the course of their psychiatric illness.
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Affiliation(s)
- Hina Ansari
- Institute of Health Policy, Management, and Evaluation, Dalla Lana School of Public Health, University of Toronto, Toronto, Ontario, Canada
| | - Susan Jaglal
- Institute of Health Policy, Management, and Evaluation, Dalla Lana School of Public Health, University of Toronto, Toronto, Ontario, Canada
- Toronto Rehabilitation Institute, University Health Network, Toronto, Ontario, Canada
- Department of Physical Therapy, University of Toronto, Toronto, Ontario, Canada
- ICES, Toronto, Ontario, Canada
| | - Angela M Cheung
- Department of Medicine and Joint Department of Medical Imaging, University Health Network and Sinai Health System, University of Toronto, Toronto, Ontario, Canada
| | - Paul Kurdyak
- Institute of Health Policy, Management, and Evaluation, Dalla Lana School of Public Health, University of Toronto, Toronto, Ontario, Canada
- ICES, Toronto, Ontario, Canada
- Department of Psychiatry, Temerty Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada
- Centre for Addiction and Mental Health, Toronto, Ontario, Canada
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14
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Sun LY, Chu A, Tam DY, Wang X, Fang J, Austin PC, Feindel CM, Alexopoulos V, Tusevljak N, Rocha R, Ouzounian M, Woodward G, Lee DS. Derivation and validation of predictive indices for cardiac readmission after coronary and valvular surgery - A multicenter study. AMERICAN HEART JOURNAL PLUS : CARDIOLOGY RESEARCH AND PRACTICE 2023; 28:100285. [PMID: 38511073 PMCID: PMC10946031 DOI: 10.1016/j.ahjo.2023.100285] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 04/18/2022] [Revised: 02/01/2023] [Accepted: 02/28/2023] [Indexed: 03/22/2024]
Abstract
Objective To derive and validate models to predict the risk of a cardiac readmission within one year after specific cardiac surgeries using information that is commonly available from hospital electronic medical records. Methods In this retrospective cohort study, we derived and externally validated clinical models to predict the likelihood of cardiac readmissions within one-year of isolated CABG, AVR, and combined CABG+AVR in Ontario, Canada, using multiple clinical registries and routinely collected administrative databases. For all adult patients who underwent these procedures, multiple Fine and Gray subdistribution hazard models were derived within a competing-risk framework using the cohort from April 2015 to March 2018 and validated in an independent cohort (April 2018 to March 2020). Results For the model that predicted post-CABG cardiac readmission, the c-statistic was 0.73 in the derivation cohort and 0.70 in the validation cohort at one-year. For the model that predicted post-AVR cardiac readmission, the c-statistic was 0.74 in the derivation and 0.73 in the validation cohort at one-year. For the model that predicted cardiac readmission following CABG+AVR, the c-statistic was 0.70 in the derivation and 0.66 in the validation cohort at one-year. Conclusions Prediction of one-year cardiac readmission for isolated CABG, AVR, and combined CABG+AVR can be achieved parsimoniously using multidimensional data sources. Model discrimination was better than existing models derived from single and multicenter registries.
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Affiliation(s)
- Louise Y. Sun
- Department of Anesthesiology, Perioperative and Pain Medicine, Stanford University School of Medicine, Stanford, CA, USA
- ICES, Toronto, Ontario, Canada
| | | | - Derrick Y. Tam
- ICES, Toronto, Ontario, Canada
- Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
- Department of Medicine, University of Toronto, Toronto, Ontario, Canada
| | | | | | - Peter C. Austin
- ICES, Toronto, Ontario, Canada
- Institute of Health Policy, Management, and Evaluation, University of Toronto, Toronto, Ontario, Canada
| | - Christopher M. Feindel
- Department of Medicine, University of Toronto, Toronto, Ontario, Canada
- Peter Munk Cardiac Centre, University Health Network, Toronto, Ontario, Canada
| | | | | | | | - Maral Ouzounian
- Department of Medicine, University of Toronto, Toronto, Ontario, Canada
- Peter Munk Cardiac Centre, University Health Network, Toronto, Ontario, Canada
| | | | - Douglas S. Lee
- ICES, Toronto, Ontario, Canada
- Department of Medicine, University of Toronto, Toronto, Ontario, Canada
- Peter Munk Cardiac Centre, University Health Network, Toronto, Ontario, Canada
| | - CorHealth Ontario Cardiac Surgery Risk Adjustment Task Force
- Department of Anesthesiology, Perioperative and Pain Medicine, Stanford University School of Medicine, Stanford, CA, USA
- ICES, Toronto, Ontario, Canada
- Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
- Department of Medicine, University of Toronto, Toronto, Ontario, Canada
- Institute of Health Policy, Management, and Evaluation, University of Toronto, Toronto, Ontario, Canada
- Peter Munk Cardiac Centre, University Health Network, Toronto, Ontario, Canada
- Ontario Health, Toronto, Ontario, Canada
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15
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Park S, Park SJ, Park DW. Percutaneous Coronary Intervention Versus Coronary Artery Bypass Grafting for Revascularization of Left Main Coronary Artery Disease. Korean Circ J 2023; 53:113-133. [PMID: 36914602 PMCID: PMC10011221 DOI: 10.4070/kcj.2022.0333] [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: 12/26/2022] [Accepted: 01/24/2023] [Indexed: 03/03/2023] Open
Abstract
Owing to a large-jeopardized myocardium, left main coronary artery disease (LMCAD) represents the substantial high-risk anatomical subset of obstructive coronary artery disease. For several decades, coronary artery bypass grafting (CABG) has been the "gold standard" treatment for LMCAD. Along with advances in CABG, percutaneous coronary intervention (PCI) has also dramatically evolved over time in conjunction with advances in the stent or device technology, adjunct pharmacotherapy, accumulated experiences, and practice changes, establishing its position as a safe, reasonable treatment option for such a complex disease. Until recently, several randomized clinical trials, meta-analyses, and observational registries comparing PCI and CABG for LMCAD have shown comparable long-term survival with tradeoffs between early and late risk-benefit of each treatment. Despite this, there are still several unmet issues for revascularization strategy and management for LMCAD. This review article summarized updated knowledge on evolution and clinical evidence on the treatment of LMCAD, with a focus on the comparison of state-of-the-art PCI with CABG.
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Affiliation(s)
- Sangwoo Park
- Department of Cardiology, Ulsan University Hospital, University of Ulsan College of Medicine, Ulsan, Korea
| | - Seung-Jung Park
- Department of Cardiology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Duk-Woo Park
- Department of Cardiology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea.
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16
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Damluji AA, Forman DE, Wang TY, Chikwe J, Kunadian V, Rich MW, Young BA, Page RL, DeVon HA, Alexander KP. Management of Acute Coronary Syndrome in the Older Adult Population: A Scientific Statement From the American Heart Association. Circulation 2023; 147:e32-e62. [PMID: 36503287 DOI: 10.1161/cir.0000000000001112] [Citation(s) in RCA: 62] [Impact Index Per Article: 62.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
Diagnostic and therapeutic advances during the past decades have substantially improved health outcomes for patients with acute coronary syndrome. Both age-related physiological changes and accumulated cardiovascular risk factors increase the susceptibility to acute coronary syndrome over a lifetime. Compared with younger patients, outcomes for acute coronary syndrome in the large and growing demographic of older adults are relatively worse. Increased atherosclerotic plaque burden and complexity of anatomic disease, compounded by age-related cardiovascular and noncardiovascular comorbid conditions, contribute to the worse prognosis observed in older individuals. Geriatric syndromes, including frailty, multimorbidity, impaired cognitive and physical function, polypharmacy, and other complexities of care, can undermine the therapeutic efficacy of guidelines-based treatments and the resiliency of older adults to survive and recover, as well. In this American Heart Association scientific statement, we (1) review age-related physiological changes that predispose to acute coronary syndrome and management complexity; (2) describe the influence of commonly encountered geriatric syndromes on cardiovascular disease outcomes; and (3) recommend age-appropriate and guideline-concordant revascularization and acute coronary syndrome management strategies, including transitions of care, the use of cardiac rehabilitation, palliative care services, and holistic approaches. The primacy of individualized risk assessment and patient-centered care decision-making is highlighted throughout.
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17
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Fottinger A, Eddeen AB, Lee DS, Woodward G, Sun LY. Derivation and validation of pragmatic clinical models to predict hospital length of stay after cardiac surgery in Ontario, Canada: a population-based cohort study. CMAJ Open 2023; 11:E180-E190. [PMID: 36854454 PMCID: PMC9981165 DOI: 10.9778/cmajo.20220103] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 03/02/2023] Open
Abstract
BACKGROUND Cardiac surgery is resource intensive and often requires multidisciplinary involvement to facilitate discharge. To facilitate evidence-based resource planning, we derived and validated clinical models to predict postoperative hospital length of stay (LOS). METHODS We used linked, population-level databases with information on all Ontario residents and included patients aged 18 years or older who underwent coronary artery bypass grafting, valvular or thoracic aorta surgeries between October 2008 and September 2019. The primary outcome was hospital LOS. The models were derived by using patients who had surgery before Sept. 30, 2016, and validated after that date. To address the rightward skew in LOS data and to identify top-tier resource users, we used logistic regression to derive a model to predict the likelihood of LOS being more than the 98th percentile (> 30 d), and γ regression in the remainder to predict continuous LOS in days. We used backward stepwise variable selection for both models. RESULTS Among 105 193 patients, 2422 (2.3%) had an LOS of more than 30 days. Factors predicting prolonged LOS included age, female sex, procedure type and urgency, comorbidities including frailty, high-risk acute coronary syndrome, heart failure, reduced left ventricular ejection fraction and psychiatric and pulmonary circulatory disease. The C statistic was 0.92 for the prolonged LOS model and the mean absolute error was 2.4 days for the continuous LOS model. INTERPRETATION We derived and validated clinical models to identify top-tier resource users and predict continuous LOS with excellent accuracy. Our models could be used to benchmark clinical performance based on expected LOS, rationally allocate resources and support patient-centred operative decision-making.
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Affiliation(s)
- Alexandra Fottinger
- Department of Anesthesiology, Perioperative and Pain Medicine (Sun), Stanford University School of Medicine, Stanford, CA; Team Soleil Data Laboratory (Fottinger, Sun), University of Ottawa Heart Institute, Ottawa, Ont.; ICES uOttawa (Bader Eddeen, Sun), Ottawa, Ont.; ICES Central (Lee); Peter Munk Cardiac Centre (Lee), University Health Network, University of Toronto, Toronto, Ont.; CorHealth Ontario (Woodward), Toronto, Ont
| | - Anan Bader Eddeen
- Department of Anesthesiology, Perioperative and Pain Medicine (Sun), Stanford University School of Medicine, Stanford, CA; Team Soleil Data Laboratory (Fottinger, Sun), University of Ottawa Heart Institute, Ottawa, Ont.; ICES uOttawa (Bader Eddeen, Sun), Ottawa, Ont.; ICES Central (Lee); Peter Munk Cardiac Centre (Lee), University Health Network, University of Toronto, Toronto, Ont.; CorHealth Ontario (Woodward), Toronto, Ont
| | - Douglas S Lee
- Department of Anesthesiology, Perioperative and Pain Medicine (Sun), Stanford University School of Medicine, Stanford, CA; Team Soleil Data Laboratory (Fottinger, Sun), University of Ottawa Heart Institute, Ottawa, Ont.; ICES uOttawa (Bader Eddeen, Sun), Ottawa, Ont.; ICES Central (Lee); Peter Munk Cardiac Centre (Lee), University Health Network, University of Toronto, Toronto, Ont.; CorHealth Ontario (Woodward), Toronto, Ont
| | - Graham Woodward
- Department of Anesthesiology, Perioperative and Pain Medicine (Sun), Stanford University School of Medicine, Stanford, CA; Team Soleil Data Laboratory (Fottinger, Sun), University of Ottawa Heart Institute, Ottawa, Ont.; ICES uOttawa (Bader Eddeen, Sun), Ottawa, Ont.; ICES Central (Lee); Peter Munk Cardiac Centre (Lee), University Health Network, University of Toronto, Toronto, Ont.; CorHealth Ontario (Woodward), Toronto, Ont
| | - Louise Y Sun
- Department of Anesthesiology, Perioperative and Pain Medicine (Sun), Stanford University School of Medicine, Stanford, CA; Team Soleil Data Laboratory (Fottinger, Sun), University of Ottawa Heart Institute, Ottawa, Ont.; ICES uOttawa (Bader Eddeen, Sun), Ottawa, Ont.; ICES Central (Lee); Peter Munk Cardiac Centre (Lee), University Health Network, University of Toronto, Toronto, Ont.; CorHealth Ontario (Woodward), Toronto, Ont.
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18
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Bishawi M, Hattler B, Almassi GH, Quin JA, Grover FL, Collins JF, Ebrahimi R, Wolbrom DH, Shroyer AL. Health-related quality of life impacts upon 5-year survival after coronary artery bypass surgery. J Card Surg 2022; 37:4899-4905. [PMID: 36423254 DOI: 10.1111/jocs.17165] [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: 09/27/2022] [Accepted: 10/27/2022] [Indexed: 11/26/2022]
Abstract
BACKGROUND Poor preoperative health-related quality of life (HRQoL) has been associated with reduced short-term survival after coronary artery bypass graft (CABG) surgery; however, its impact on long-term mortality is unknown. This study's objective was to determine if baseline HRQoL status predicts 5-year post-CABG mortality. METHODS This prespecified, randomized on/off bypass follow-up study (ROOBY-FS) subanalysis compared baseline patient characteristics and HRQoL scores, obtained from the Seattle Angina Questionnaire (SAQ) and Veterans RAND Short Form-36 (VR-36), between 5-year post-CABG survivors and nonsurvivors. Standardized subscores were calculated for each questionnaire. Multivariable logistic regression assessed whether HRQoL survey subcomponents independently predicted 5-year mortality (p ≤ .05). RESULTS Of the 2203 ROOBY-FS enrollees, 2104 (95.5%) completed baseline surveys. Significant differences between 5-year post-CABG deaths (n = 286) and survivors (n = 1818) included age, history of chronic obstructive pulmonary disease, stroke, peripheral vascular disease, renal dysfunction, diabetes, lower left ventricular ejection fraction, atrial fibrillation, depression, non-White race/ethnicity, lower education status, and off-pump CABG. Adjusting for these factors, baseline VR-36 physical component summary score (p = .01), VR-36 mental component summary score (p < .001), and SAQ physical limitation score (p = .003) were all associated with 5-year all-cause mortality. CONCLUSIONS Pre-CABG HRQoL scores may provide clinically relevant prognostic information beyond traditional risk models and prove useful for patient-provider shared decision-making and enhancing pre-CABG informed consent.
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Affiliation(s)
- Muath Bishawi
- Department of Surgery, Duke University, Durham, North Carolina, USA
| | - Brack Hattler
- Rocky Mountain Regional Veterans Affairs Medical Center, Aurora, Colorado, USA.,Division of Cardiology, University of Colorado School of Medicine, Aurora, Colorado, USA
| | - G Hossein Almassi
- Department of Surgery, Clement J. Zablocki Veterans Affairs (VA) Medical Center, Milwaukee, Wisconsin, USA.,Department of Surgery, Division of Cardiothoracic Surgery, Medical College of Wisconsin, Milwaukee, Wisconsin, USA
| | - Jacquelyn A Quin
- Department of Surgery, Division of Cardiac Surgery, VA Boston Healthcare System, Boston, Massachusetts, USA
| | - Frederick L Grover
- Department of Surgery, Division of Cardiothoracic Surgery, University of Colorado School of Medicine, Denver, Colorado, USA
| | - Joseph F Collins
- Cooperative Studies Program Coordinating Center, Veterans Affairs Medical Center, Perry Point, Maryland, USA
| | - Ramin Ebrahimi
- Department of Cardiology, Veterans Affairs Greater Los Angeles Healthcare System, Los Angeles, California, USA.,Department of Medicine, University of California Los Angeles, Los Angeles, California, USA
| | - Daniel H Wolbrom
- Northport Veterans Affairs Medical Center, Research and Development Office, Northport, New York, USA
| | - A Laurie Shroyer
- Northport Veterans Affairs Medical Center, Research and Development Office, Northport, New York, USA
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19
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Rubens FD, Clarke AE, Lee DS, Wells GA, Sun LY. Population study of sex-based outcomes after surgical aortic valve replacement. CJC Open 2022; 5:220-229. [PMID: 37013069 PMCID: PMC10066438 DOI: 10.1016/j.cjco.2022.12.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/24/2022] [Accepted: 12/02/2022] [Indexed: 12/12/2022] Open
Abstract
Background Surgical aortic valve replacement (SAVR) is a key strategy for the treatment of aortic valve disease. However, studies have involved primarily male patients, and whether the benefits of this approach can be extrapolated to female patients is unclear. Methods Clinical and administrative datasets for 12,207 patients undergoing isolated SAVR in Ontario from 2008 to 2019 were linked. Male and female patients were balanced using inverse probability treatment weighting. Mortality, endocarditis, and major hemorrhagic and thrombotic events, as well as 2 composite outcomes-major adverse cerebral and cardiovascular events (MACCE) and patient-derived adverse cardiovascular and noncardiovascular events (PACE)-and their component events, were compared in the weighted groups with a stratified log-rank test. Results A total of 7485 male patients and 4722 female patients were included in the study. Median follow-up was 5.2 years in both sexes. All-cause mortality did not differ between sexes (hazard ratio [HR] 0.949 [95% confidence interval {CI} 0.851-1.059]). Male sex was associated with an increased risk of new-onset dialysis (HR 0.689 [95% CI 0.488-0.974]). Female sex was associated with a significantly increased risk of both new-onset heart failure (HR 1.211 [95% CI 1.051-1.394], P = 0.0081) and heart failure hospitalization (HR 1.200 [95% CI 1.036-1.390], P = 0.015). No statistically significant differences were seen in any of the other secondary outcomes between sexes. Conclusions This population health study demonstrated that survival did not differ between male and female patients undergoing SAVR. Significant sex-related differences were found in the risk of heart failure and new-onset dialysis, but these findings should be considered exploratory and require further study.
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Sun LY, Jabagi H, Fang J, Lee DS. Comparison of Multidimensional Frailty Instruments for Estimation of Long-term Patient-Centered Outcomes After Cardiac Surgery. JAMA Netw Open 2022; 5:e2230959. [PMID: 36083582 PMCID: PMC9463609 DOI: 10.1001/jamanetworkopen.2022.30959] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/11/2022] [Accepted: 06/28/2022] [Indexed: 12/24/2022] Open
Abstract
Importance Little is known about the performance of available frailty instruments in estimating patient-relevant outcomes after cardiac surgery. Objective To examine how well the Johns Hopkins Adjusted Clinical Groups (ACG) frailty indicator, the Hospital Frailty Risk Score (HFRS), and the Preoperative Frailty Index (PFI) estimate long-term patient-centered outcomes after cardiac surgery. Design, Setting, and Participants This retrospective cohort study was conducted in Ontario, Canada, among residents 18 years and older who underwent coronary artery bypass grafting or aortic, mitral or tricuspid valve, or thoracic aorta surgery between October 2008 and March 2017. Long-term care residents, those with discordant surgical encounters, and those receiving dialysis or dependent on a ventilator within 90 days were excluded. Statistical analysis was conducted from July 2021 to January 2022. Main Outcomes and Measures The primary outcome was patient-defined adverse cardiovascular and noncardiovascular events (PACE), defined as the composite of severe stroke, heart failure, long-term care admission, new-onset dialysis, and ventilator dependence. Secondary outcomes included mortality and individual PACE events. The association between frailty and PACE was examined using cause-specific hazard models with death as a competing risk, and the association between frailty and death was examined using Cox models. Areas under the receiver operating characteristic curve (AUROC) were determined over 10 years of follow-up for each frailty instrument. Results Of 88 456 patients (22 924 [25.9%] female; mean [SD] age, 66.3 [11.1] years), 14 935 (16.9%) were frail according to ACG criteria, 63 095 (71.3%) according to HFRS, and 76 754 (86.8%) according to PFI. Patients with frailty were more likely to be older, female, and rural residents; to have lower income and multimorbidity; and to undergo urgent surgery. Patients meeting ACG criteria (hazard ratio [HR], 1.66; 95% CI, 1.60-1.71) and those with higher HFRS scores (HR per 1.0-point increment, 1.10; 95% CI, 1.09-1.10) and PFI scores (HR per 0.1-point increment, 1.75; 95% CI, 1.73-1.78) had higher rates of PACE. Similar magnitudes of association were observed for each frailty instrument with death and individual PACE components. The HFRS had the highest AUROC for estimating PACE during the first 2 years and death during the first 4 years, after which the PFI had the highest AUROC. Conclusions and Relevance These findings could help to tailor the use of frailty instruments by outcome and follow-up duration, thus optimizing preoperative risk stratification, patient-centered decision-making, candidate selection for prehabilitation, and personalized monitoring and health resource planning in patients undergoing cardiac surgery.
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Affiliation(s)
- Louise Y. Sun
- Division of Cardiac Anesthesiology, University of Ottawa Heart Institute, Ottawa, Ontario, Canada
- Cardiovascular Research Program, Institute for Clinical Evaluative Sciences, Toronto, Ontario, Canada
- School of Epidemiology and Public Health, University of Ottawa, Ottawa, Ontario, Canada
| | - Habib Jabagi
- Division of Cardiac Surgery, Valley Health System, Ridgewood, New Jersey
| | - Jiming Fang
- Cardiovascular Research Program, Institute for Clinical Evaluative Sciences, Toronto, Ontario, Canada
| | - Douglas S. Lee
- Cardiovascular Research Program, Institute for Clinical Evaluative Sciences, Toronto, Ontario, Canada
- Division of Cardiology, University Health Network and Peter Munk Cardiac Centre, Toronto, Ontario, Canada
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Chronic Coronary Syndrome in Frail Old Population. LIFE (BASEL, SWITZERLAND) 2022; 12:life12081133. [PMID: 36013312 PMCID: PMC9410393 DOI: 10.3390/life12081133] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 06/23/2022] [Revised: 07/23/2022] [Accepted: 07/25/2022] [Indexed: 12/30/2022]
Abstract
The demographic trend of aging is associated with an increased prevalence of comorbidities among the elderly. Physical, immunological, emotional and cognitive impairment, in the context of the advanced biological age segment, leads to the maintenance and precipitation of cardiovascular diseases. Thus, more and more data are focused on understanding the pathophysiological mechanisms underlying each fragility phenotype and how they potentiate each other. The implications of inflammation, sarcopenia, vitamin D deficiency and albumin, as dimensions inherent in fragility, in the development and setting of chronic coronary syndromes (CCSs) have proven their patent significance but are still open to research. At the same time, the literature speculates on the interdependent relationship between frailty and CCSs, revealing the role of the first one in the development of the second. In this sense, depression, disabilities, polypharmacy and even cognitive disorders in the elderly with ischemic cardiovascular disease mean a gradual and complex progression of frailty. The battery of tests necessary for the evaluation of the elderly with CCSs requires a permanent update, according to the latest guidelines, but also an individualized approach related to the degree of frailty and the conditions imposed by it. By summation, the knowledge of frailty screening methods, through the use of sensitive and individualized tools, is the foundation of secondary prevention and prognosis in the elderly with CCSs. Moreover, a comprehensive geriatric assessment remains the gold standard of the medical approach of these patients. The management of the frail elderly, with CCSs, brings new challenges, also from the perspective of the treatment particularities. Sometimes the risk–benefit balance is difficult to achieve. Therefore, the holistic, individualized and updated approach of these patients remains a desired objective, by understanding and permanently acquiring knowledge on the complexity of the frailty syndrome.
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22
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Chan AK, Shahrestani S, Ballatori AM, Orrico KO, Manley GT, Tarapore PE, Huang M, Dhall SS, Chou D, Mummaneni PV, DiGiorgio AM. Is the Centers for Medicare and Medicaid Services Hierarchical Condition Category Risk Adjustment Model Satisfactory for Quantifying Risk After Spine Surgery? Neurosurgery 2022; 91:123-131. [PMID: 35550453 PMCID: PMC9514755 DOI: 10.1227/neu.0000000000001980] [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: 07/23/2021] [Accepted: 01/12/2022] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND The Centers for Medicare and Medicaid Services (CMS) hierarchical condition category (HCC) coding is a risk adjustment model that allows for the estimation of risk-and cost-associated with health care provision. Current models may not include key factors that fully delineate the risk associated with spine surgery. OBJECTIVE To augment CMS HCC risk adjustment methodology with socioeconomic data to improve its predictive capabilities for spine surgery. METHODS The National Inpatient Sample was queried for spinal fusion, and the data was merged with county-level coverage and socioeconomic status variables obtained from the Brookings Institute. We predicted outcomes (death, nonroutine discharge, length of stay [LOS], total charges, and perioperative complication) with pairs of hierarchical, mixed effects logistic regression models-one using CMS HCC score alone and another augmenting CMS HCC scores with demographic and socioeconomic status variables. Models were compared using receiver operating characteristic curves. Variable importance was assessed in conjunction with Wald testing for model optimization. RESULTS We analyzed 653 815 patients. Expanded models outperformed models using CMS HCC score alone for mortality, nonroutine discharge, LOS, total charges, and complications. For expanded models, variable importance analyses demonstrated that CMS HCC score was of chief importance for models of mortality, LOS, total charges, and complications. For the model of nonroutine discharge, age was the most important variable. For the model of total charges, unemployment rate was nearly as important as CMS HCC score. CONCLUSION The addition of key demographic and socioeconomic characteristics substantially improves the CMS HCC risk-adjustment models when modeling spinal fusion outcomes. This finding may have important implications for payers, hospitals, and policymakers.
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Affiliation(s)
- Andrew K. Chan
- Department of Neurological Surgery, University of California, San Francisco, California, USA
- Department of Neurosurgery, Duke University, Durham, North Carolina, USA
| | - Shane Shahrestani
- Department of Medical Engineering, California Institute of Technology, Pasadena, California, USA
- Keck School of Medicine, University of Southern California, Los Angeles, California, USA
| | - Alexander M. Ballatori
- Keck School of Medicine, University of Southern California, Los Angeles, California, USA
| | - Katie O. Orrico
- American Association of Neurological Surgeons/Congress of Neurological Surgeons Washington Office, Washington, District of Columbia, USA
| | - Geoffrey T. Manley
- Department of Neurological Surgery, University of California, San Francisco, California, USA
| | - Phiroz E. Tarapore
- Department of Neurological Surgery, University of California, San Francisco, California, USA
| | - Michael Huang
- Department of Neurological Surgery, University of California, San Francisco, California, USA
| | - Sanjay S. Dhall
- Department of Neurological Surgery, University of California, San Francisco, California, USA
| | - Dean Chou
- Department of Neurological Surgery, University of California, San Francisco, California, USA
| | - Praveen V. Mummaneni
- Department of Neurological Surgery, University of California, San Francisco, California, USA
| | - Anthony M. DiGiorgio
- Department of Neurological Surgery, University of California, San Francisco, California, USA
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Bakhsheshian J, Shahrestani S, Buser Z, Hah R, Hsieh PC, Liu JC, Wang JC. The performance of frailty in predictive modeling of short-term outcomes in the surgical management of metastatic tumors to the spine. Spine J 2022; 22:605-615. [PMID: 34848345 DOI: 10.1016/j.spinee.2021.11.015] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/28/2021] [Revised: 11/10/2021] [Accepted: 11/22/2021] [Indexed: 02/03/2023]
Abstract
BACKGROUND CONTEXT The concept of frailty has become increasingly recognized, and while patients with cancer are at increased risk for frailty, its influence on perioperative outcomes in metastatic spine tumors is uncertain. Furthermore, the impact of frailty can be confounded by comorbidities or metastatic disease burden. PURPOSE The purpose of this study was to evaluate the influence of frailty and comorbidities on adverse outcomes in the surgical management of metastatic spine disease. STUDY DESIGN/SETTING Retrospective analysis of a nationwide database to include patients undergoing spinal fusion for metastatic spine disease. PATIENT SAMPLE A total of 1,974 frail patients who received spinal fusion with spinal metastasis, and 1,975 propensity score matched non-frail patients. OUTCOME MEASURES Outcomes analyzed included mortality, complications, length of stay (LOS), nonroutine discharges and costs. METHODS A validated binary frailty index (Johns Hopkins Adjusted Clinical Groups) was used to identify frail and non-frail groups, and propensity score-matched analysis (including demographics, comorbidities, surgical and tumor characteristics) was performed. Sub-group analysis of levels involved was performed for cervical, thoracic, lumbar and junctional spine. Multivariable-regression techniques were used to develop predictive models for outcomes using frailty and the Elixhauser Comorbidity Index (ECI). RESULTS 7,772 patients underwent spinal fusion with spinal metastasis, of which 1,974 (25.4%) patients were identified as frail. Following propensity score matching for frail (n=1,974) and not-frail (n=1,975) groups, frailty demonstrated significantly greater medical complications (OR=1.58; 95% CI 1.33-1.86), surgical complications (OR=1.46; 95% CI 1.15-1.85), LOS (OR=2.65; 95% CI 2.09-3.37), nonroutine discharges (OR=1.79; 95% CI 1.46-2.20) and costs (OR=1.68; 95% CI 1.32-2.14). Differences in mortality were only observed in subgroup analysis and were greater in frail junctional and lumbar spine subgroups. Models using ECI alone (AUC=0.636-0.788) demonstrated greater predictive ability compared to those using frailty alone (AUC=0.633-0.752). However, frailty combined with ECI improved the prediction of increased LOS (AUC=0.811), cost (AUC=0.768), medical complications (AUC=0.723) and nonroutine discharges (AUC=0.718). Predictive modeling of frailty in subgroups demonstrated the greatest performance for mortality (AUC=0.750) in the lumbar spine, otherwise performed similarly for LOS, costs, complications, and discharge across subgroups. CONCLUSIONS A high prevalence of frailty existed in the current patient cohort. Frailty contributed to worse short-term adverse outcomes and could be more influential in the lumbar and junctional spine due to higher risk of deconditioning in the postoperative period. Predictions for short term outcomes can be improved by adding frailty to comorbidity indices, suggesting a more comprehensive preoperative risk stratification should include frailty.
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Affiliation(s)
- Joshua Bakhsheshian
- Department of Neurological Surgery, Keck School of Medicine, University of Southern California, Los Angeles, CA, USA
| | - Shane Shahrestani
- Department of Neurological Surgery, Keck School of Medicine, University of Southern California, Los Angeles, CA, USA; Department of Medical Engineering, California Institute of Technology, Pasadena, CA, USA
| | - Zorica Buser
- Department of Neurological Surgery, Keck School of Medicine, University of Southern California, Los Angeles, CA, USA; Department of Orthopaedic Surgery, Keck School of Medicine, University of Southern California, Los Angeles, CA, USA.
| | - Raymond Hah
- Department of Orthopaedic Surgery, Keck School of Medicine, University of Southern California, Los Angeles, CA, USA
| | - Patrick C Hsieh
- Department of Neurological Surgery, Keck School of Medicine, University of Southern California, Los Angeles, CA, USA
| | - John C Liu
- Department of Neurological Surgery, Keck School of Medicine, University of Southern California, Los Angeles, CA, USA
| | - Jeffrey C Wang
- Department of Neurological Surgery, Keck School of Medicine, University of Southern California, Los Angeles, CA, USA; Department of Orthopaedic Surgery, Keck School of Medicine, University of Southern California, Los Angeles, CA, USA
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Wleklik M, Denfeld Q, Lisiak M, Czapla M, Kałużna-Oleksy M, Uchmanowicz I. Frailty Syndrome in Older Adults with Cardiovascular Diseases-What Do We Know and What Requires Further Research? INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2022; 19:ijerph19042234. [PMID: 35206422 PMCID: PMC8872246 DOI: 10.3390/ijerph19042234] [Citation(s) in RCA: 12] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 12/18/2021] [Revised: 02/08/2022] [Accepted: 02/14/2022] [Indexed: 02/07/2023]
Abstract
Cardiovascular diseases (CVD) affect 60% of people over 60 years of age and are one of the main causes of death in the world. Diagnosed cardiovascular disease also triples the likelihood of Frailty syndrome (FS). FS has become increasingly relevant in cardiology and cardiac surgery and occurs in a significant number of patients with CVD, with prevalence ranging from 25% to 62%. Viewed in a multidimensional, biopsychosocial perspective, FS increases a patient's vulnerability, making them susceptible to several adverse clinical outcomes. Frailty syndrome also is a predictor of mortality in patients with CVD regardless of age, severity of disease, multi-morbidity, and disability. Frailty syndrome potentially can be prevented in patients with CVD and its early identification is important to avoid the development of disability, dependence on others and reduced quality of life. The aim of this paper is to show the relationship between FS and specific CVDs (coronary artery disease, hypertension, atrial fibrillation, heart failure) and cardiac procedures (device implantation, cardiac surgery, and transcatheter aortic valve implantation). Furthermore, we highlight those areas that require further research to fully understand the relationship between FS and CVD and to be able to minimize or prevent its adverse effects.
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Affiliation(s)
- Marta Wleklik
- Department of Nursing and Obstetrics, Faculty of Health Sciences, Wroclaw Medical University, 51-618 Wroclaw, Poland; (M.W.); (M.L.); (I.U.)
- Institute of Heart Diseases, University Hospital, 50-566 Wroclaw, Poland
| | - Quin Denfeld
- School of Nursing, Oregon Health and Science University, Portland, OR 97239, USA;
| | - Magdalena Lisiak
- Department of Nursing and Obstetrics, Faculty of Health Sciences, Wroclaw Medical University, 51-618 Wroclaw, Poland; (M.W.); (M.L.); (I.U.)
- Institute of Heart Diseases, University Hospital, 50-566 Wroclaw, Poland
| | - Michał Czapla
- Institute of Heart Diseases, University Hospital, 50-566 Wroclaw, Poland
- Laboratory for Experimental Medicine and Innovative Technologies, Department of Emergency Medical Service, Wroclaw Medical University, 51-616 Wroclaw, Poland
- Correspondence:
| | - Marta Kałużna-Oleksy
- 1st Department of Cardiology, University of Medical Sciences in Poznan, 61-848 Poznan, Poland;
| | - Izabella Uchmanowicz
- Department of Nursing and Obstetrics, Faculty of Health Sciences, Wroclaw Medical University, 51-618 Wroclaw, Poland; (M.W.); (M.L.); (I.U.)
- Institute of Heart Diseases, University Hospital, 50-566 Wroclaw, Poland
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Sun LY, Jones PM, Wijeysundera DN, Mamas MA, Bader Eddeen A, O’Connor J. Association Between Handover of Anesthesiology Care and 1-Year Mortality Among Adults Undergoing Cardiac Surgery. JAMA Netw Open 2022; 5:e2148161. [PMID: 35147683 PMCID: PMC8837916 DOI: 10.1001/jamanetworkopen.2021.48161] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/09/2021] [Accepted: 11/28/2021] [Indexed: 01/28/2023] Open
Abstract
Importance Handovers of anesthesia care from one anesthesiologist to another is an important intraoperative event. Despite its association with adverse events after noncardiac surgery, its impact in the context of cardiac surgery remains unclear. Objective To compare the outcomes of patients who were exposed to anesthesia handover vs those who were unexposed to anesthesia handover during cardiac surgery. Design, Setting, and Participants This retrospective cohort study in Ontario, Canada, included Ontario residents who were 18 years or older and had undergone coronary artery bypass grafting or aortic, mitral, tricuspid valve, or thoracic aorta surgical procedures between 2008 and 2019. Exclusion criteria were non-Ontario residency status and other concomitant procedures. Statistical analysis was conducted from April 2021 to June 2021, and data collection occurred between November 2020 to January 2021. Exposures Complete handover of anesthesia care, where the case is completed by the replacement anesthesiologist. Main Outcomes and Measures The coprimary outcomes were mortality within 30 days and 1 year after surgery. Secondary outcomes were patient-defined adverse cardiac and noncardiac events (PACE), intensive care unit (ICU), and hospital lengths of stay (LOS). Inverse probability of treatment weighting based on the propensity score was used to estimate adjusted effect measures. Mortality was assessed using a Cox proportional hazard model, PACE using a cause-specific hazard model with death as a competing risk, and LOS using Poisson regression. Results Of the 102 156 patients in the cohort, 25 207 (24.7%) were women; the mean (SD) age was 66.4 (10.8) years; and 72 843 of surgical procedures (71.3%) were performed in teaching hospitals. Handover occurred in 1926 patients (1.9%) and was associated with higher risks of 30-day mortality (hazard ratio [HR], 1.89; 95% CI, 1.41-2.54) and 1-year mortality (HR, 1.66; 95% CI, 1.31-2.12), as well as longer ICU (risk ratio [RR], 1.43; 95% CI, 1.22-1.68) and hospital (RR, 1.17; 95% CI, 1.06-1.28) LOS. There was no statistically significant association between handover and PACE (30 days: HR 1.09; 95% CI, 0.79-1.49; 1 year: HR 0.89; 95% CI, 0.70-1.13). Conclusions and Relevance Handover of anesthesia care during cardiac surgical procedures was associated with higher 30-day and 1-year mortality rates and increased health care resource use. Further research is needed to evaluate and systematically improve the handover process qualitatively.
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Affiliation(s)
- Louise Y. Sun
- Division of Cardiac Anesthesiology, University of Ottawa Heart Institute, Ottawa, Ontario, Canada
- ICES, Ontario, Canada
- School of Epidemiology and Public Health, University of Ottawa, Ottawa, Ontario, Canada
| | - Philip M. Jones
- ICES, Ontario, Canada
- Departments of Anesthesia and Perioperative Medicine and Epidemiology and Biostatistics, University of Western Ontario, London, Ontario, Canada
| | - Duminda N. Wijeysundera
- ICES, Ontario, Canada
- Department of Anesthesiology and Pain Medicine, University of Toronto, Toronto, Ontario, Canada
- Department of Anesthesia, St Michael’s Hospital, Toronto, Ontario, Canada
| | - Mamas A. Mamas
- Keele Cardiovascular Research Group, Centre for Prognosis Research, Keele University and Institute for Population Health, University of Manchester, United Kingdom
| | | | - John O’Connor
- Division of Cardiac Anesthesiology, University of Ottawa Heart Institute, Ottawa, Ontario, Canada
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Sun LY, Wijeysundera HC, Lee DS, van Diepen S, Ruel M, Eddeen AB, Mesana TG. Derivation and validation of a clinical risk score to predict death among patients awaiting cardiac surgery in Ontario, Canada: a population-based study. CMAJ Open 2022; 10:E173-E182. [PMID: 35260467 PMCID: PMC9259465 DOI: 10.9778/cmajo.20210031] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
BACKGROUND Surgical delay may result in unintended harm to patients needing cardiac surgery, who are at risk for death if their condition is left untreated. Our objective was to derive and internally validate a clinical risk score to predict death among patients awaiting major cardiac surgery. METHODS We used the CorHealth Ontario Registry and linked ICES health administrative databases with information on all Ontario residents to identify patients aged 18 years or more who were referred for isolated coronary artery bypass grafting (CABG), valvular procedures, combined CABG-valvular procedures or thoracic aorta procedures between Oct. 1, 2008, and Sept. 30, 2019. We used a hybrid modelling approach with the random forest method for initial variable selection, followed by backward stepwise logistic regression modelling for clinical interpretability and parsimony. We internally validated the logistic regression model, termed the CardiOttawa Waitlist Mortality Score, using 200 bootstraps. RESULTS Of the 112 266 patients referred for cardiac surgery, 269 (0.2%) died while awaiting surgery (118/72 366 [0.2%] isolated CABG, 81/24 461 [0.3%] valvular procedures, 63/12 046 [0.5%] combined CABG-valvular procedures and 7/3393 [0.2%] thoracic aorta procedures). Age, sex, surgery type, left main stenosis, Canadian Cardiovascular Society classification, left ventricular ejection fraction, heart failure, atrial fibrillation, dialysis, psychosis and operative priority were predictors of waitlist mortality. The model discriminated (C-statistic 0.76 [optimism-corrected 0.73]). It calibrated well in the overall cohort (Hosmer-Lemeshow p = 0.2) and across surgery types. INTERPRETATION The CardiOttawa Waitlist Mortality Score is a simple clinical risk model that predicts the likelihood of death while awaiting cardiac surgery. It has the potential to provide data-driven decision support for managing access to cardiac care and preserve system capacity during the COVID-19 pandemic, the recovery period and beyond.
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Affiliation(s)
- Louise Y Sun
- Division of Cardiac Anesthesiology (Sun), University of Ottawa Heart Institute; School of Epidemiology and Public Health (Sun), University of Ottawa, Ottawa, Ont.; ICES (Sun, Wijeysundera, Lee, Eddeen); Schulich Heart Program (Wijeysundera), Sunnybrook Health Sciences Centre; Division of Cardiology (Wijeysundera), Department of Medicine, University of Toronto; Institute of Health Policy, Management and Evaluation (Wijeysundera), University of Toronto; Peter Munk Cardiac Centre (Lee), University Health Network, University of Toronto, Toronto, Ont.; Department of Critical Care Medicine (van Diepen), University of Alberta; Division of Cardiology (van Diepen), Department of Medicine, University of Alberta, Edmonton, Alta.; Division of Cardiac Surgery (Ruel, Mesana), University of Ottawa Heart Institute, Ottawa, Ont.
| | - Harindra C Wijeysundera
- Division of Cardiac Anesthesiology (Sun), University of Ottawa Heart Institute; School of Epidemiology and Public Health (Sun), University of Ottawa, Ottawa, Ont.; ICES (Sun, Wijeysundera, Lee, Eddeen); Schulich Heart Program (Wijeysundera), Sunnybrook Health Sciences Centre; Division of Cardiology (Wijeysundera), Department of Medicine, University of Toronto; Institute of Health Policy, Management and Evaluation (Wijeysundera), University of Toronto; Peter Munk Cardiac Centre (Lee), University Health Network, University of Toronto, Toronto, Ont.; Department of Critical Care Medicine (van Diepen), University of Alberta; Division of Cardiology (van Diepen), Department of Medicine, University of Alberta, Edmonton, Alta.; Division of Cardiac Surgery (Ruel, Mesana), University of Ottawa Heart Institute, Ottawa, Ont
| | - Douglas S Lee
- Division of Cardiac Anesthesiology (Sun), University of Ottawa Heart Institute; School of Epidemiology and Public Health (Sun), University of Ottawa, Ottawa, Ont.; ICES (Sun, Wijeysundera, Lee, Eddeen); Schulich Heart Program (Wijeysundera), Sunnybrook Health Sciences Centre; Division of Cardiology (Wijeysundera), Department of Medicine, University of Toronto; Institute of Health Policy, Management and Evaluation (Wijeysundera), University of Toronto; Peter Munk Cardiac Centre (Lee), University Health Network, University of Toronto, Toronto, Ont.; Department of Critical Care Medicine (van Diepen), University of Alberta; Division of Cardiology (van Diepen), Department of Medicine, University of Alberta, Edmonton, Alta.; Division of Cardiac Surgery (Ruel, Mesana), University of Ottawa Heart Institute, Ottawa, Ont
| | - Sean van Diepen
- Division of Cardiac Anesthesiology (Sun), University of Ottawa Heart Institute; School of Epidemiology and Public Health (Sun), University of Ottawa, Ottawa, Ont.; ICES (Sun, Wijeysundera, Lee, Eddeen); Schulich Heart Program (Wijeysundera), Sunnybrook Health Sciences Centre; Division of Cardiology (Wijeysundera), Department of Medicine, University of Toronto; Institute of Health Policy, Management and Evaluation (Wijeysundera), University of Toronto; Peter Munk Cardiac Centre (Lee), University Health Network, University of Toronto, Toronto, Ont.; Department of Critical Care Medicine (van Diepen), University of Alberta; Division of Cardiology (van Diepen), Department of Medicine, University of Alberta, Edmonton, Alta.; Division of Cardiac Surgery (Ruel, Mesana), University of Ottawa Heart Institute, Ottawa, Ont
| | - Marc Ruel
- Division of Cardiac Anesthesiology (Sun), University of Ottawa Heart Institute; School of Epidemiology and Public Health (Sun), University of Ottawa, Ottawa, Ont.; ICES (Sun, Wijeysundera, Lee, Eddeen); Schulich Heart Program (Wijeysundera), Sunnybrook Health Sciences Centre; Division of Cardiology (Wijeysundera), Department of Medicine, University of Toronto; Institute of Health Policy, Management and Evaluation (Wijeysundera), University of Toronto; Peter Munk Cardiac Centre (Lee), University Health Network, University of Toronto, Toronto, Ont.; Department of Critical Care Medicine (van Diepen), University of Alberta; Division of Cardiology (van Diepen), Department of Medicine, University of Alberta, Edmonton, Alta.; Division of Cardiac Surgery (Ruel, Mesana), University of Ottawa Heart Institute, Ottawa, Ont
| | - Anan Bader Eddeen
- Division of Cardiac Anesthesiology (Sun), University of Ottawa Heart Institute; School of Epidemiology and Public Health (Sun), University of Ottawa, Ottawa, Ont.; ICES (Sun, Wijeysundera, Lee, Eddeen); Schulich Heart Program (Wijeysundera), Sunnybrook Health Sciences Centre; Division of Cardiology (Wijeysundera), Department of Medicine, University of Toronto; Institute of Health Policy, Management and Evaluation (Wijeysundera), University of Toronto; Peter Munk Cardiac Centre (Lee), University Health Network, University of Toronto, Toronto, Ont.; Department of Critical Care Medicine (van Diepen), University of Alberta; Division of Cardiology (van Diepen), Department of Medicine, University of Alberta, Edmonton, Alta.; Division of Cardiac Surgery (Ruel, Mesana), University of Ottawa Heart Institute, Ottawa, Ont
| | - Thierry G Mesana
- Division of Cardiac Anesthesiology (Sun), University of Ottawa Heart Institute; School of Epidemiology and Public Health (Sun), University of Ottawa, Ottawa, Ont.; ICES (Sun, Wijeysundera, Lee, Eddeen); Schulich Heart Program (Wijeysundera), Sunnybrook Health Sciences Centre; Division of Cardiology (Wijeysundera), Department of Medicine, University of Toronto; Institute of Health Policy, Management and Evaluation (Wijeysundera), University of Toronto; Peter Munk Cardiac Centre (Lee), University Health Network, University of Toronto, Toronto, Ont.; Department of Critical Care Medicine (van Diepen), University of Alberta; Division of Cardiology (van Diepen), Department of Medicine, University of Alberta, Edmonton, Alta.; Division of Cardiac Surgery (Ruel, Mesana), University of Ottawa Heart Institute, Ottawa, Ont
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Pai SL, Jacob AK, Wang RD. Preoperative optimization of geriatric and frail patients. Int Anesthesiol Clin 2022; 60:33-42. [PMID: 34456275 DOI: 10.1097/aia.0000000000000340] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Affiliation(s)
- Sher-Lu Pai
- Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Jacksonville, Florida
| | - Adam K Jacob
- Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Rochester, Minnesota
| | - R Doris Wang
- Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Jacksonville, Florida
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Ahola R, Siiki A, Rinta-Kiikka I, Laitinen I, Antila A, Jämsen E, Laukkarinen J. Preoperative measures predicting outcome after pancreatic resection in aged patients. Scand J Surg 2022; 111:14574969221083136. [PMID: 35333104 DOI: 10.1177/14574969221083136] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
BACKGROUND AND OBJECTIVE High-risk surgery on aged patients raises challenging ethical and clinical issues. The aim of this study was to analyze the preoperative factors associated with severe complications and returning home after pancreatic resection among patients aged ⩾ 75 years. PATIENTS AND METHODS Patients aged ⩾ 75 years undergoing pancreatic resection in 2012-2019 were retrospectively searched from the hospital database. Preoperative indices (Clinical Frailty Scale, Skeletal Muscle Index, Geriatric Nutritional Risk Index, Charlson Comorbidity Index, and National Surgical Quality Improvement Program risk for severe complications) were determined. Postoperative outcome was evaluated by incidence of Clavien-Dindo 3b-5 complications, rate of returning home, and 1-year survival. RESULTS A total of 95 patients were included. American Society of Anesthesiologists Class 3-4 covered 50%, Clinical Frailty Scale > 3 22%, Charlson Comorbidity Index > 6 53%, and a sarcopenic Skeletal Muscle Index 51% of these patients. The National Surgical Quality Improvement Program risk for severe complications was higher than average among 21% of patients. Geriatric Nutritional Risk Index showed high risk among 3% of them. In total, 19 patients (20%) experienced a severe (Clavien-Dindo 3b-5) complication. However, 30- and 90-day mortality was 2.1%. Preoperative indices were not associated with severe complications. Most patients (79%) had returned home within 8 weeks of surgery. Not returning home was associated with severe complications (p = 0.010). CONCLUSIONS The short-term outcome after pancreatic resection of fit older patients is similar to that of younger, unselected patient groups. In these selected patients, the commonly used preoperative indexes were not associated with severe complications or returning home.
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Affiliation(s)
- Reea Ahola
- Department of Gastroenterology and Alimentary Tract Surgery Tampere University Hospital Teiskontie 35 Tampere 33210 Finland
| | - Antti Siiki
- Department of Gastroenterology and Alimentary Tract Surgery, Tampere University Hospital, Tampere, Finland
| | | | - Ismo Laitinen
- Central Hospital of South Ostrobothnia, Seinäjoki, Finland
| | - Anne Antila
- Department of Gastroenterology and Alimentary Tract Surgery, Tampere University Hospital, Tampere, Finland
| | - Esa Jämsen
- Department of Geriatrics, Tampere University Hospital, Tampere, Finland Tampere University, Tampere, Finland
| | - Johanna Laukkarinen
- Department of Gastroenterology and Alimentary Tract Surgery, Tampere University Hospital, Tampere, Finland Tampere University, Tampere, Finland
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Frailty as a Predictor of Postoperative Outcomes in Invasive Cardiac Surgery: A Systematic Review of Literature. J Cardiovasc Nurs 2022; 37:231-247. [PMID: 34016838 PMCID: PMC8602435 DOI: 10.1097/jcn.0000000000000821] [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] [Indexed: 01/03/2023]
Abstract
OBJECTIVES Frailty is a syndrome characterized by increased vulnerability and reduced ability to maintain homeostasis after stressful events that results in an increased risk for poor outcomes. Frailty screening could potentially be valuable in cardiac surgery risk assessment. The purpose of this review is to evaluate the current literature linking multicomponent frailty assessment and invasive cardiac surgery outcomes. METHODS We searched PubMed, EMBASE, and CINAHL; 1887 articles met the search criteria, and each was independently reviewed by 2 reviewers. RESULTS The 19 eligible studies assessed 52 291 subjects using 17 different frailty measurements. The most commonly used instruments were the Fried Frailty Phenotype and the Clinical Frailty Scale. Between 9% and 61% of participants were found to be frail in each study. All 19 studies included mortality as an outcome, 12 included surgical complications, 12 included hospital length of stay, 3 included quality of life, and 2 included functional status. Nine found statistically significant differences in survival between frail and nonfrail patients, 6 of 12 found that frail patients had a longer length of stay, 4 of 12 found that frail patients were more likely to experience major complications, and 2 of 2 found that frail patients were more likely to have a decrease in functional status. CONCLUSION Although some studies lacked power, the majority confirmed that frail patients are more likely to experience poor outcomes. Further research is needed to determine which frailty measure provides the best predictive validity and to identify interventions to mitigate the risks that major cardiac surgery poses to frail patients.
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Sarkar S, MacLeod JB, Hassan A, Dutton DJ, Brunt KR, Légaré JF. An age-independent hospital record-based frailty score correlates with adverse outcomes after heart surgery and increased health care costs. JTCVS OPEN 2021; 8:491-502. [PMID: 36004086 PMCID: PMC9390592 DOI: 10.1016/j.xjon.2021.10.018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 12/10/2020] [Accepted: 10/19/2021] [Indexed: 10/29/2022]
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Sun LY, Chu A, Tam DY, Wang X, Fang J, Austin PC, Feindel CM, Oakes GH, Alexopoulos V, Tusevljak N, Ouzounian M, Lee DS. Derivation and validation of predictive indices for 30-day mortality after coronary and valvular surgery in Ontario, Canada. CMAJ 2021; 193:E1757-E1765. [PMID: 34810162 PMCID: PMC8608458 DOI: 10.1503/cmaj.202901] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/23/2021] [Indexed: 01/21/2023] Open
Abstract
Background: Coronary artery bypass grafting (CABG) and surgical aortic valve replacement (AVR) are the 2 most common cardiac surgery procedures in North America. We derived and externally validated clinical models to estimate the likelihood of death within 30 days of CABG, AVR or combined CABG + AVR. Methods: We obtained data from the CorHealth Ontario Cardiac Registry and several linked population health administrative databases from Ontario, Canada. We derived multiple logistic regression models from all adult patients who underwent CABG, AVR or combined CABG + AVR from April 2017 to March 2019, and validated them in 2 temporally distinct cohorts (April 2015 to March 2017 and April 2019 to March 2020). Results: The derivation cohorts included 13 435 patients who underwent CABG (30-d mortality 1.73%), 1970 patients who underwent AVR (30-d mortality 1.68%) and 1510 patients who underwent combined CABG + AVR (30-d mortality 3.05%). The final models for predicting 30-day mortality included 15 variables for patients undergoing CABG, 5 variables for patients undergoing AVR and 5 variables for patients undergoing combined CABG + AVR. Model discrimination was excellent for the CABG (c-statistic 0.888, optimism-corrected 0.866) AVR (c-statistic 0.850, optimism-corrected 0.762) and CABG + AVR (c-statistic 0.844, optimism-corrected 0.776) models, with similar results in the validation cohorts. Interpretation: Our models, leveraging readily available, multidimensional data sources, computed accurate risk-adjusted 30-day mortality rates for CABG, AVR and combined CABG + AVR, with discrimination comparable to more complex American and European models. The ability to accurately predict perioperative mortality rates for these procedures will be valuable for quality improvement initiatives across institutions.
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Affiliation(s)
- Louise Y Sun
- Division of Cardiac Anesthesiology (Sun), University of Ottawa Heart Institute, Ottawa, Ont.; ICES Central (Sun, Chu, Tam, Wang, Fang, Austin, Tusevljak, Lee), Toronto, Ont.; School of Epidemiology and Public Health (Sun), University of Ottawa, Ottawa, Ont.; Sunnybrook Health Sciences Centre (Tam); University Health Network and Peter Munk Cardiac Centre (Feindel, Ouzounian, Lee); Departments of Cardiac Surgery (Tam, Feindel, Ouzounian), Physical Therapy (Chu), Surgery (Feindel), Cardiology (Lee), University of Toronto, Toronto, Ont.; Institute for Health Policy, Management and Evaluation (Austin), University of Toronto, Toronto, Ont.; CorHealth Ontario (Oakes, Alexopoulos), Toronto, Ont
| | - Anna Chu
- Division of Cardiac Anesthesiology (Sun), University of Ottawa Heart Institute, Ottawa, Ont.; ICES Central (Sun, Chu, Tam, Wang, Fang, Austin, Tusevljak, Lee), Toronto, Ont.; School of Epidemiology and Public Health (Sun), University of Ottawa, Ottawa, Ont.; Sunnybrook Health Sciences Centre (Tam); University Health Network and Peter Munk Cardiac Centre (Feindel, Ouzounian, Lee); Departments of Cardiac Surgery (Tam, Feindel, Ouzounian), Physical Therapy (Chu), Surgery (Feindel), Cardiology (Lee), University of Toronto, Toronto, Ont.; Institute for Health Policy, Management and Evaluation (Austin), University of Toronto, Toronto, Ont.; CorHealth Ontario (Oakes, Alexopoulos), Toronto, Ont
| | - Derrick Y Tam
- Division of Cardiac Anesthesiology (Sun), University of Ottawa Heart Institute, Ottawa, Ont.; ICES Central (Sun, Chu, Tam, Wang, Fang, Austin, Tusevljak, Lee), Toronto, Ont.; School of Epidemiology and Public Health (Sun), University of Ottawa, Ottawa, Ont.; Sunnybrook Health Sciences Centre (Tam); University Health Network and Peter Munk Cardiac Centre (Feindel, Ouzounian, Lee); Departments of Cardiac Surgery (Tam, Feindel, Ouzounian), Physical Therapy (Chu), Surgery (Feindel), Cardiology (Lee), University of Toronto, Toronto, Ont.; Institute for Health Policy, Management and Evaluation (Austin), University of Toronto, Toronto, Ont.; CorHealth Ontario (Oakes, Alexopoulos), Toronto, Ont
| | - Xuesong Wang
- Division of Cardiac Anesthesiology (Sun), University of Ottawa Heart Institute, Ottawa, Ont.; ICES Central (Sun, Chu, Tam, Wang, Fang, Austin, Tusevljak, Lee), Toronto, Ont.; School of Epidemiology and Public Health (Sun), University of Ottawa, Ottawa, Ont.; Sunnybrook Health Sciences Centre (Tam); University Health Network and Peter Munk Cardiac Centre (Feindel, Ouzounian, Lee); Departments of Cardiac Surgery (Tam, Feindel, Ouzounian), Physical Therapy (Chu), Surgery (Feindel), Cardiology (Lee), University of Toronto, Toronto, Ont.; Institute for Health Policy, Management and Evaluation (Austin), University of Toronto, Toronto, Ont.; CorHealth Ontario (Oakes, Alexopoulos), Toronto, Ont
| | - Jiming Fang
- Division of Cardiac Anesthesiology (Sun), University of Ottawa Heart Institute, Ottawa, Ont.; ICES Central (Sun, Chu, Tam, Wang, Fang, Austin, Tusevljak, Lee), Toronto, Ont.; School of Epidemiology and Public Health (Sun), University of Ottawa, Ottawa, Ont.; Sunnybrook Health Sciences Centre (Tam); University Health Network and Peter Munk Cardiac Centre (Feindel, Ouzounian, Lee); Departments of Cardiac Surgery (Tam, Feindel, Ouzounian), Physical Therapy (Chu), Surgery (Feindel), Cardiology (Lee), University of Toronto, Toronto, Ont.; Institute for Health Policy, Management and Evaluation (Austin), University of Toronto, Toronto, Ont.; CorHealth Ontario (Oakes, Alexopoulos), Toronto, Ont
| | - Peter C Austin
- Division of Cardiac Anesthesiology (Sun), University of Ottawa Heart Institute, Ottawa, Ont.; ICES Central (Sun, Chu, Tam, Wang, Fang, Austin, Tusevljak, Lee), Toronto, Ont.; School of Epidemiology and Public Health (Sun), University of Ottawa, Ottawa, Ont.; Sunnybrook Health Sciences Centre (Tam); University Health Network and Peter Munk Cardiac Centre (Feindel, Ouzounian, Lee); Departments of Cardiac Surgery (Tam, Feindel, Ouzounian), Physical Therapy (Chu), Surgery (Feindel), Cardiology (Lee), University of Toronto, Toronto, Ont.; Institute for Health Policy, Management and Evaluation (Austin), University of Toronto, Toronto, Ont.; CorHealth Ontario (Oakes, Alexopoulos), Toronto, Ont
| | - Christopher M Feindel
- Division of Cardiac Anesthesiology (Sun), University of Ottawa Heart Institute, Ottawa, Ont.; ICES Central (Sun, Chu, Tam, Wang, Fang, Austin, Tusevljak, Lee), Toronto, Ont.; School of Epidemiology and Public Health (Sun), University of Ottawa, Ottawa, Ont.; Sunnybrook Health Sciences Centre (Tam); University Health Network and Peter Munk Cardiac Centre (Feindel, Ouzounian, Lee); Departments of Cardiac Surgery (Tam, Feindel, Ouzounian), Physical Therapy (Chu), Surgery (Feindel), Cardiology (Lee), University of Toronto, Toronto, Ont.; Institute for Health Policy, Management and Evaluation (Austin), University of Toronto, Toronto, Ont.; CorHealth Ontario (Oakes, Alexopoulos), Toronto, Ont
| | - Garth H Oakes
- Division of Cardiac Anesthesiology (Sun), University of Ottawa Heart Institute, Ottawa, Ont.; ICES Central (Sun, Chu, Tam, Wang, Fang, Austin, Tusevljak, Lee), Toronto, Ont.; School of Epidemiology and Public Health (Sun), University of Ottawa, Ottawa, Ont.; Sunnybrook Health Sciences Centre (Tam); University Health Network and Peter Munk Cardiac Centre (Feindel, Ouzounian, Lee); Departments of Cardiac Surgery (Tam, Feindel, Ouzounian), Physical Therapy (Chu), Surgery (Feindel), Cardiology (Lee), University of Toronto, Toronto, Ont.; Institute for Health Policy, Management and Evaluation (Austin), University of Toronto, Toronto, Ont.; CorHealth Ontario (Oakes, Alexopoulos), Toronto, Ont
| | - Vicki Alexopoulos
- Division of Cardiac Anesthesiology (Sun), University of Ottawa Heart Institute, Ottawa, Ont.; ICES Central (Sun, Chu, Tam, Wang, Fang, Austin, Tusevljak, Lee), Toronto, Ont.; School of Epidemiology and Public Health (Sun), University of Ottawa, Ottawa, Ont.; Sunnybrook Health Sciences Centre (Tam); University Health Network and Peter Munk Cardiac Centre (Feindel, Ouzounian, Lee); Departments of Cardiac Surgery (Tam, Feindel, Ouzounian), Physical Therapy (Chu), Surgery (Feindel), Cardiology (Lee), University of Toronto, Toronto, Ont.; Institute for Health Policy, Management and Evaluation (Austin), University of Toronto, Toronto, Ont.; CorHealth Ontario (Oakes, Alexopoulos), Toronto, Ont
| | - Natasa Tusevljak
- Division of Cardiac Anesthesiology (Sun), University of Ottawa Heart Institute, Ottawa, Ont.; ICES Central (Sun, Chu, Tam, Wang, Fang, Austin, Tusevljak, Lee), Toronto, Ont.; School of Epidemiology and Public Health (Sun), University of Ottawa, Ottawa, Ont.; Sunnybrook Health Sciences Centre (Tam); University Health Network and Peter Munk Cardiac Centre (Feindel, Ouzounian, Lee); Departments of Cardiac Surgery (Tam, Feindel, Ouzounian), Physical Therapy (Chu), Surgery (Feindel), Cardiology (Lee), University of Toronto, Toronto, Ont.; Institute for Health Policy, Management and Evaluation (Austin), University of Toronto, Toronto, Ont.; CorHealth Ontario (Oakes, Alexopoulos), Toronto, Ont
| | - Maral Ouzounian
- Division of Cardiac Anesthesiology (Sun), University of Ottawa Heart Institute, Ottawa, Ont.; ICES Central (Sun, Chu, Tam, Wang, Fang, Austin, Tusevljak, Lee), Toronto, Ont.; School of Epidemiology and Public Health (Sun), University of Ottawa, Ottawa, Ont.; Sunnybrook Health Sciences Centre (Tam); University Health Network and Peter Munk Cardiac Centre (Feindel, Ouzounian, Lee); Departments of Cardiac Surgery (Tam, Feindel, Ouzounian), Physical Therapy (Chu), Surgery (Feindel), Cardiology (Lee), University of Toronto, Toronto, Ont.; Institute for Health Policy, Management and Evaluation (Austin), University of Toronto, Toronto, Ont.; CorHealth Ontario (Oakes, Alexopoulos), Toronto, Ont
| | - Douglas S Lee
- Division of Cardiac Anesthesiology (Sun), University of Ottawa Heart Institute, Ottawa, Ont.; ICES Central (Sun, Chu, Tam, Wang, Fang, Austin, Tusevljak, Lee), Toronto, Ont.; School of Epidemiology and Public Health (Sun), University of Ottawa, Ottawa, Ont.; Sunnybrook Health Sciences Centre (Tam); University Health Network and Peter Munk Cardiac Centre (Feindel, Ouzounian, Lee); Departments of Cardiac Surgery (Tam, Feindel, Ouzounian), Physical Therapy (Chu), Surgery (Feindel), Cardiology (Lee), University of Toronto, Toronto, Ont.; Institute for Health Policy, Management and Evaluation (Austin), University of Toronto, Toronto, Ont.; CorHealth Ontario (Oakes, Alexopoulos), Toronto, Ont.
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Coffey S, Dixit P, Saw EL, Babakr AA, van Hout I, Galvin IF, Saxena P, Bunton RW, Davis PJ, Lamberts RR, Katare R, Williams MJA. Thiamine increases resident endoglin positive cardiac progenitor cells and atrial contractile force in humans: A randomised controlled trial. Int J Cardiol 2021; 341:70-73. [PMID: 34461161 DOI: 10.1016/j.ijcard.2021.08.039] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/06/2021] [Revised: 08/13/2021] [Accepted: 08/24/2021] [Indexed: 10/20/2022]
Abstract
BACKGROUND The heart has an intrinsic ability to regenerate, orchestrated by progenitor or stem cells. However, the relative complexity of non-resident cardiac progenitor cell (CPC) therapy makes modulation of resident CPCs a more attractive treatment target. Thiamine analogues improve resident CPC function in pre-clinical models. In this double blinded randomised controlled trial (identifier: ACTRN12614000755639), we examined whether thiamine would improve CPC function in humans. METHODS AND RESULTS High dose oral thiamine (one gram twice daily) or matching placebo was administered 3-5 days prior to coronary artery bypass surgery (CABG). Right atrial appendages were collected at the time of CABG, and CPCs isolated. There was no difference in the primary outcome (proliferation ability of CPCs) between treatment groups. Older age was not associated with decreased proliferation ability. In exploratory analyses, isolated CPCs in the thiamine group showed an increase in the proportion of CD34-/CD105+ (endoglin) cells, but no difference in CD34-/CD90+ or CD34+ cells. Thiamine increased maximum force developed by isolated trabeculae, with no difference in relaxation time or beta-adrenergic responsiveness. CONCLUSION Thiamine does not improve proliferation ability of CPC in patients undergoing CABG, but increases the proportion of CD34-/CD105+ cells. Having not met its primary endpoint, this study provides the impetus to re-examine CPC biology prior to any clinical outcome-based trial examining potential beneficial cardiovascular effects of thiamine.
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Affiliation(s)
- Sean Coffey
- Department of Medicine - HeartOtago, Dunedin School of Medicine, University of Otago, New Zealand; Department of Cardiology, Southern District Health Board, New Zealand.
| | - Parul Dixit
- Department of Physiology - HeartOtago, School of Biomedical Sciences, University of Otago, New Zealand
| | - Eng Leng Saw
- Department of Physiology - HeartOtago, School of Biomedical Sciences, University of Otago, New Zealand
| | - Aram A Babakr
- Department of Physiology - HeartOtago, School of Biomedical Sciences, University of Otago, New Zealand
| | - Isabelle van Hout
- Department of Physiology - HeartOtago, School of Biomedical Sciences, University of Otago, New Zealand
| | - Ivor F Galvin
- Department of Cardiothoracic Surgery, Southern District Health Board, New Zealand
| | - Pankaj Saxena
- Department of Cardiothoracic Surgery, Southern District Health Board, New Zealand
| | - Richard W Bunton
- Department of Cardiothoracic Surgery, Southern District Health Board, New Zealand
| | - Philip J Davis
- Department of Cardiothoracic Surgery, Southern District Health Board, New Zealand
| | - Regis R Lamberts
- Department of Physiology - HeartOtago, School of Biomedical Sciences, University of Otago, New Zealand
| | - Rajesh Katare
- Department of Physiology - HeartOtago, School of Biomedical Sciences, University of Otago, New Zealand
| | - Michael J A Williams
- Department of Medicine - HeartOtago, Dunedin School of Medicine, University of Otago, New Zealand; Department of Cardiology, Southern District Health Board, New Zealand
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Anand PA, Keshavamurthy S, Shelley EM, Saha S. Does Age Affect the Short- and Long-Term Outcomes of Coronary Bypass Grafting? Int J Angiol 2021; 30:202-211. [PMID: 34776820 PMCID: PMC8580610 DOI: 10.1055/s-0041-1735221] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022] Open
Abstract
The etiology of coronary artery disease (CAD) is multifactorial, stemming from both modifiable and nonmodifiable risk factors such as age. Several studies have reported the effects of age on various outcomes of coronary artery bypass grafting (CABG). This article reviews age-related outcomes of CABG and offers direction for further studies in the field to create comprehensive, evidence-based guidelines for the treatment of CAD. Ninety-two primary sources were analyzed for relevance to the subject matter, of which 17 were selected for further analysis: 14 retrospective cohort studies, 2 randomized clinical trials, and 1 meta-analysis. Our review revealed four broad age ranges into which patients can be grouped: those with CAD (1) below the age of 40 years, (2) between the ages of 40 and 60 years, (3) between the ages of 60 and 80 years, and (4) at or above 80 years. Patients below the age of 40 years fare best overall with total arterial revascularization (TAR). Patients between the ages of 40 and 60 years also fare well with the use of multiarterial grafts (MAGs) whereas either MAGs or single-arterial grafts may be of significant benefit to patients at or above the age of 60 years, with younger and diabetic patients benefitting the most. Arterial grafting is superior to vein grafting until the age of 80 years, at which point there is promising evidence supporting the continued use of the saphenous vein as the favored graft substrate. Age is a factor affecting the outcomes of CABG but should not serve as a barrier to offering patients CABG at any age from either a cost or a health perspective. Operative intervention starts to show significant mortality consequences at the age of 80 years, but the increased risk is countered by maintenance or improvement to patients' quality of life.
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Affiliation(s)
- Pavan Ashwini Anand
- Division of Cardiothoracic Surgery, Department of Surgery, University of Kentucky College of Medicine, Lexington, Kentucky
| | - Suresh Keshavamurthy
- Division of Cardiothoracic Surgery, Department of Surgery, University of Kentucky College of Medicine, Lexington, Kentucky
| | - Ellis M. Shelley
- Division of Cardiothoracic Surgery, Department of Surgery, University of Kentucky College of Medicine, Lexington, Kentucky
| | - Sibu Saha
- Division of Cardiothoracic Surgery, Department of Surgery, University of Kentucky College of Medicine, Lexington, Kentucky
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Sun LY, Boet S, Chan V, Lee DS, Mesana TG, Bader Eddeen A, Etherington C. Impact of surgeon and anaesthesiologist sex on patient outcomes after cardiac surgery: a population-based study. BMJ Open 2021; 11:e051192. [PMID: 34433609 PMCID: PMC8388286 DOI: 10.1136/bmjopen-2021-051192] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/15/2021] [Accepted: 08/05/2021] [Indexed: 01/02/2023] Open
Abstract
BACKGROUND Effective teamwork between anaesthesiologists and surgeons is essential for optimising patient safety in the cardiac operating room. While many factors may influence the relationship between these two physicians, the role of sex and gender have yet to be investigated. OBJECTIVES We sought to determine the association between cardiac physician team sex discordance and patient outcomes. DESIGN We performed a population-based, retrospective cohort study. PARTICIPANTS AND SETTING Adult patients who underwent coronary artery bypass grafting (CABG) and/or aortic, mitral or tricuspid valve surgery between 2008 and 2018 in Ontario, Canada. PRIMARY AND SECONDARY OUTCOME MEASURES The primary outcome was all-cause 30-day mortality. Secondary outcomes included major adverse cardiovascular events at 30 days and hospital and intensive care unit lengths of stay (LOS). Mixed effects logistic regression was used for categorical outcomes and Poisson regression for continuous outcomes. RESULTS 79 862 patients underwent cardiac surgery by 98 surgeons (11.2% female) and 279 anaesthesiologists (23.3% female); 19 893 (24.9%) were treated by sex-discordant physician teams. Physician sex discordance was not associated with overall patient mortality or LOS; however, patients who underwent isolated CABG experienced longer hospital LOS when treated by an all-male physician team as compared with an all-female team (adjusted OR=1.07; p=0.049). When examining the impact of individual physician sex, the length of hospital stay was longer when isolated CABG procedures were attended by a male surgeon (OR=1.10; p=0.004) or anaesthesiologist (OR=1.02; p=0.01). CONCLUSIONS Patient mortality and length of stay after cardiac surgery may vary by sex concordance of the attending surgeon-anaesthesiologist team. Further research is needed to examine the underlying mechanisms of these observed relationships.
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Affiliation(s)
- Louise Y Sun
- Division of Cardiac Anesthesiology, University of Ottawa Heart Institute, Ottawa, Ontario, Canada
- Cardiovascular Research Program, Institute for Clinical Evaluative Sciences, Toronto, Ontario, Canada
- School of Epidemiology and Public Health, University of Ottawa, Ottawa, Ontario, Canada
- Department of Anesthesiology and Pain Medicine, University of Ottawa Faculty of Medicine, Ottawa, Ontario, Canada
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
| | - Sylvain Boet
- Department of Anesthesiology and Pain Medicine, University of Ottawa Faculty of Medicine, Ottawa, Ontario, Canada
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
- Department of Innovation in Medical Education, University of Ottawa, Ottawa, Ontario, Canada
| | - Vincent Chan
- Division of Cardiac Surgery, University of Ottawa Heart Institute, Ottawa, Ontario, Canada
| | - Douglas S Lee
- Cardiovascular Research Program, Institute for Clinical Evaluative Sciences, Toronto, Ontario, Canada
- Peter Munk Cardiac Centre, University Health Network, Toronto, Ontario, Canada
| | - Thierry G Mesana
- Division of Cardiac Surgery, University of Ottawa Heart Institute, Ottawa, Ontario, Canada
| | - Anan Bader Eddeen
- Cardiovascular Research Program, Institute for Clinical Evaluative Sciences, Toronto, Ontario, Canada
| | - Cole Etherington
- Department of Anesthesiology and Pain Medicine, University of Ottawa Faculty of Medicine, Ottawa, Ontario, Canada
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
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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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Hadaya J, Sanaiha Y, Juillard C, Benharash P. Impact of frailty on clinical outcomes and resource use following emergency general surgery in the United States. PLoS One 2021; 16:e0255122. [PMID: 34297772 PMCID: PMC8301636 DOI: 10.1371/journal.pone.0255122] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2021] [Accepted: 07/09/2021] [Indexed: 12/02/2022] Open
Abstract
Background Frailty has been recognized as an independent risk factor for inferior outcomes, but its effect on emergency general surgery (EGS) is understudied. Objective The purpose of the present study was to define the impact of frailty on risk-adjusted mortality, non-home discharge, and readmission following EGS operations. Methods Adults undergoing appendectomy, cholecystectomy, small bowel resection, large bowel resection, repair of perforated ulcer, or laparotomy within two days of an urgent admission were identified in the 2016–2017 Nationwide Readmissions Database. Frailty was defined using diagnosis codes corresponding to the Johns Hopkins Adjusted Clinical Groups frailty indicator. Multivariable regression was used to study in-hospital mortality and non-home discharge by operation, and Kaplan Meier analysis to study freedom from unplanned readmission at up to 90-days follow-up. Results Among 655,817 patients, 11.9% were considered frail. Frail patients most commonly underwent large bowel resection (37.3%) and cholecystectomy (29.2%). After adjustment, frail patients had higher mortality rates for all operations compared to nonfrail, including those most commonly performed (11.9% [95% CI 11.4–12.5%] vs 6.0% [95% CI 5.8–6.3%] for large bowel resection; 2.3% [95% CI 2.0–2.6%] vs 0.2% [95% CI 0.2–0.2%] for cholecystectomy). Adjusted non-home discharge rates were higher for frail compared to nonfrail patients following all operations, including large bowel resection (68.1% [95% CI 67.1–69.0%] vs 25.9% [95% CI 25.2–26.5%]) and cholecystectomy (33.7% [95% CI 32.7–34.7%] vs 2.9% [95% CI 2.8–3.0%]). Adjusted hospitalization costs were nearly twice as high for frail patients. On Kaplan-Meier analysis, frail patients had greater unplanned readmissions (log rank P<0.001), with 1 in 4 rehospitalized within 90 days. Conclusions Frail patients have inferior clinical outcomes and greater resource use following EGS, with the greatest absolute differences following complex operations. Simple frailty assessments may inform expectations, identify patients at risk of poor outcomes, and guide the need for more intensive postoperative care.
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Affiliation(s)
- Joseph Hadaya
- Division of Cardiac Surgery, Department of Surgery, David Geffen School of Medicine at UCLA, Los Angeles, California, United States of America
- Division of General Surgery, Department of Surgery, David Geffen School of Medicine at UCLA, Los Angeles, California, United States of America
| | - Yas Sanaiha
- Division of Cardiac Surgery, Department of Surgery, David Geffen School of Medicine at UCLA, Los Angeles, California, United States of America
- Division of General Surgery, Department of Surgery, David Geffen School of Medicine at UCLA, Los Angeles, California, United States of America
| | - Catherine Juillard
- Division of General Surgery, Department of Surgery, David Geffen School of Medicine at UCLA, Los Angeles, California, United States of America
| | - Peyman Benharash
- Division of Cardiac Surgery, Department of Surgery, David Geffen School of Medicine at UCLA, Los Angeles, California, United States of America
- * E-mail:
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Harada G, Andrade MC, Brito JN, Tavares CDAM, Tarasoutchi F, Pomerantzeff PMA, Bortolotto L, Feltrim MIZ. Prevalence of Frailty in Patients Undergoing Cardiac Valve Surgery: Comparison of Frailty Tools. INTERNATIONAL JOURNAL OF CARDIOVASCULAR SCIENCES 2021. [DOI: 10.36660/ijcs.20200098] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022] Open
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Lee JA, Yanagawa B, An KR, Arora RC, Verma S, Friedrich JO. Frailty and pre-frailty in cardiac surgery: a systematic review and meta-analysis of 66,448 patients. J Cardiothorac Surg 2021; 16:184. [PMID: 34172059 PMCID: PMC8229742 DOI: 10.1186/s13019-021-01541-8] [Citation(s) in RCA: 51] [Impact Index Per Article: 17.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2021] [Accepted: 05/13/2021] [Indexed: 12/01/2022] Open
Abstract
BACKGROUND The burden of frailty on cardiac surgical outcomes is incompletely understood. Here we perform a systematic review and meta-analysis of studies comparing frail versus pre-frail versus non-frail patients following cardiac surgery. METHODS We searched MEDLINE and EMBASE databases until July 2018 for studies comparing cardiac surgery outcomes in "frail", "pre-frail" and "non-frail" patients. Data was extracted in duplicate. Primary outcome was operative mortality. RESULTS There were 19 observational studies with 66,448 patients. Frail patients were more likely female (risk ratio [RR]1.7; 95%CI:1.5-1.9), older (mean difference: 2.4; 95%CI:1.3-3.5 years older) with greater comorbidities and higher STS-PROM. Frailty (RR2.35; 95%CI:1.57-3.51; p < 0.0001) and pre-frailty (RR2.03; 95%CI:1.52-2.70; p < 0.00001) were associated with increased operative mortality compared with non-frail patients. Frailty was also associated with greater risk of prolonged hospital stay (RR1.83; 95%CI:1.61-2.08; p < 0.0001) and intermediate care facility discharge (RR2.71; 95%CI:1.45-5.05; p = 0.002). Frail (Hazard Ratio [HR]3.27; 95%CI:1.93-5.55; p < 0.0001) and pre-frail patients (HR2.30; 95%CI:1.29-4.09; p = 0.005) had worse mid-term mortality (median follow-up 1 years [range 0.5-4 years]). After adjustment for baseline imbalances, frailty was still associated with greater operative mortality (odds ratio [OR]1.97; 95%CI:1.51-2.57; p < 0.00001), intermediate care facility discharge (OR4.61; 95%CI:2.78-7.66; p < 0.00001) and midterm mortality (HR1.37; 95%CI:1.03-1.83; p = 0.03). CONCLUSION In patients undergoing cardiac surgery, frailty and pre-frailty were associated with 2-fold and 1.5-fold greater adjusted operative mortality, respectively, greater adjusted perioperative complications and frailty was associated with almost 5-fold risk of non-home discharge. Burden of frailty and pre-frailty on cardiac surgical outcomes.
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Affiliation(s)
- Jessica Avery Lee
- Division of Cardiac Surgery, University of Toronto, 30 Bond Street, 8th Floor, Bond Wing, Toronto, ON, M5B 1W8, Canada
| | - Bobby Yanagawa
- Division of Cardiac Surgery, University of Toronto, 30 Bond Street, 8th Floor, Bond Wing, Toronto, ON, M5B 1W8, Canada.
| | - Kevin R An
- Division of Cardiac Surgery, University of Toronto, 30 Bond Street, 8th Floor, Bond Wing, Toronto, ON, M5B 1W8, Canada
| | - Rakesh C Arora
- Department of Surgery, Max Rady College of Medicine, University of Manitoba, Winnipeg, Manitoba, Canada
| | - Subodh Verma
- Division of Cardiac Surgery, University of Toronto, 30 Bond Street, 8th Floor, Bond Wing, Toronto, ON, M5B 1W8, Canada
| | - Jan O Friedrich
- Critical Care, St Michael's Hospital, University of Toronto, Toronto, Ontario, Canada
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Alkadri J, Hage D, Nickerson LH, Scott LR, Shaw JF, Aucoin SD, McIsaac DI. A Systematic Review and Meta-Analysis of Preoperative Frailty Instruments Derived From Electronic Health Data. Anesth Analg 2021; 133:1094-1106. [PMID: 33999880 DOI: 10.1213/ane.0000000000005595] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
BACKGROUND Frailty is a strong predictor of adverse outcomes in the perioperative period. Given the increasing availability of electronic medical data, we performed a systematic review and meta-analysis with primary objectives of describing available frailty instruments applied to electronic data and synthesizing their prognostic value. Our secondary objectives were to assess the construct validity of frailty instruments that have been applied to perioperative electronic data and the feasibility of electronic frailty assessment. METHODS Following protocol registration, a peer-reviewed search strategy was applied to Medline, Excerpta Medica dataBASE (EMBASE), Cochrane databases, and the Comprehensive Index to Nursing and Allied Health literature from inception to December 31, 2019. All stages of the review were completed in duplicate. The primary outcome was mortality; secondary outcomes included nonhome discharge, health care costs, and length of stay. Effect estimates adjusted for baseline illness, sex, age, procedure, and urgency were of primary interest; unadjusted and adjusted estimates were pooled using random-effects models where appropriate or narratively synthesized. Risk of bias was assessed. RESULTS Ninety studies were included; 83 contributed to the meta-analysis. Frailty was defined using 22 different instruments. In adjusted data, frailty identified from electronic data using any instrument was associated with a 3.57-fold increase in the odds of mortality (95% confidence interval [CI], 2.68-4.75), increased odds of institutional discharge (odds ratio [OR], 2.40; 95% CI, 1.99-2.89), and increased costs (ratio of means, 1.54; 95% CI, 1.46-1.63). Most instruments were not multidimensional, head-to-head comparisons were lacking, and no feasibility data were reported. CONCLUSIONS Frailty status derived from electronic data provides prognostic value as it is associated with adverse outcomes, even after adjustment for typical risk factors. However, future research is required to evaluate multidimensional instruments and their head-to-head performance and to assess their feasibility and clinical impact.
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Affiliation(s)
- Jamal Alkadri
- From the Department of Anesthesiology & Pain Medicine
| | - Dima Hage
- Faculty of Medicine, University of Ottawa, Ottawa, Ontario, Canada
| | | | - Lia R Scott
- Department of General Surgery, Queen's University, Ottawa, Ontario, Canada
| | - Julia F Shaw
- School of Epidemiology and Public Health, University of Ottawa, Ottawa, Ontario, Canada
| | | | - Daniel I McIsaac
- From the Department of Anesthesiology & Pain Medicine.,School of Epidemiology and Public Health, University of Ottawa, Ottawa, Ontario, Canada.,Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
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Sun LY, Eddeen AB, Mesana TG. Disability-free survival after major cardiac surgery: a population-based retrospective cohort study. CMAJ Open 2021; 9:E384-E393. [PMID: 33863796 PMCID: PMC8084566 DOI: 10.9778/cmajo.20200096] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/03/2022] Open
Abstract
BACKGROUND Cardiovascular research has traditionally been dedicated to "tombstone" outcomes, with little attention dedicated to the patient's perspective. We evaluated disability-free survival as a patient-defined outcome after cardiac surgery. METHODS We conducted a retrospective cohort study of patients aged 40 years and older who underwent coronary artery bypass grafting (CABG) or single or multiple valve (aortic, mitral, tricuspid) surgery in Ontario between Oct. 1, 2008, and Dec. 31, 2016. The primary outcome was disability (a composite of stroke, 3 or more nonelective hospital admissions and admission to a long-term care facility) within 1 year after surgery. We assessed the procedure-specific risk of disability using cumulative incidence functions, and the relative effect of covariates on the subdistribution hazard using Fine and Gray models. RESULTS The study included 72 824 patients. The 1-year incidence of disability and death was 2431 (4.6%) and 1839 (3.5%) for CABG, 677 (6.5%) and 539 (5.2%) for single valve, 118 (9.0%) and 140 (10.7%) for multiple valve, 718 (9.0%) and 730 (9.2%) for CABG and single valve, and 87 (13.1%) and 94 (14.1%) for CABG and multiple valve surgery, respectively. With CABG as the reference group, the adjusted hazard ratios for disability were 1.34 (95% confidence interval [CI] 1.21-1.48) after single valve, 1.43 (95% CI 1.18-1.75) after multiple valve, 1.38 (95% CI 1.26-1.51) after CABG and single valve, and 1.78 (95% CI 1.43-2.23) after CABG and multiple valve surgery. Combined CABG and multiple valve surgery, heart failure, creatinine 180 μmol/L or greater, alcohol use disorder, dementia and depression were independent risk factors for disability. INTERPRETATION The cumulative incidence of disability was lowest after CABG and highest after combined CABG and multiple valve surgery. Our findings point to a need for models that predict personalized disability risk to enable better patient-centred care.
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Affiliation(s)
- Louise Y Sun
- The Division of Cardiac Anesthesiology, Department of Anesthesiology and Pain Medicine (Sun), University of Ottawa Heart Institute; the School of Epidemiology and Public Health (Sun), University of Ottawa; the Institute for Clinical Evaluative Sciences (Sun, Bader Eddeen); the Division of Cardiac Surgery, Department of Surgery (Mesana), University of Ottawa Heart Institute, Ottawa, Ont.
| | - Anan Bader Eddeen
- The Division of Cardiac Anesthesiology, Department of Anesthesiology and Pain Medicine (Sun), University of Ottawa Heart Institute; the School of Epidemiology and Public Health (Sun), University of Ottawa; the Institute for Clinical Evaluative Sciences (Sun, Bader Eddeen); the Division of Cardiac Surgery, Department of Surgery (Mesana), University of Ottawa Heart Institute, Ottawa, Ont
| | - Thierry G Mesana
- The Division of Cardiac Anesthesiology, Department of Anesthesiology and Pain Medicine (Sun), University of Ottawa Heart Institute; the School of Epidemiology and Public Health (Sun), University of Ottawa; the Institute for Clinical Evaluative Sciences (Sun, Bader Eddeen); the Division of Cardiac Surgery, Department of Surgery (Mesana), University of Ottawa Heart Institute, Ottawa, Ont
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Raymond E, Reynolds CA, Dahl Aslan AK, Finkel D, Ericsson M, Hägg S, Pedersen NL, Jylhävä J. Drivers of Frailty from Adulthood into Old Age: Results from a 27-Year Longitudinal Population-Based Study in Sweden. J Gerontol A Biol Sci Med Sci 2021; 75:1943-1950. [PMID: 32348465 PMCID: PMC7518563 DOI: 10.1093/gerona/glaa106] [Citation(s) in RCA: 19] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/12/2019] [Indexed: 01/05/2023] Open
Abstract
BACKGROUND Frailty is a strong predictor of adverse outcomes. However, longitudinal drivers of frailty are not well understood. This study aimed at investigating the longitudinal trajectories of a frailty index (FI) from adulthood to late life and identifying the factors associated with the level and rate of change in FI. METHODS An age-based latent growth curve analysis was performed in the Swedish Adoption/Twin Study of Aging (N = 1,842; aged 29-102 years) using data from up to 15 measurement waves across 27 years. A 42-item FI was used to measure frailty at each wave. RESULTS A bilinear, two-slope model with a turning point at age 65 best described the age-related change in FI, showing that the increase in frailty was more than twice as fast after age 65. Underweight, obesity, female sex, overweight, being separated from one's co-twin during childhood, smoking, poor social support, and low physical activity were associated with a higher FI at age 65, with underweight having the largest effect size. When tested as time-varying covariates, underweight and higher social support were associated with a steeper increase in FI before age 65, whereas overweight and obesity were associated with less steep increase in FI after age 65. CONCLUSIONS Factors associated with the level and rate of change in frailty are largely actionable and could provide targets for intervention. As deviations from normal weight showed the strongest associations with frailty, future public health programs could benefit from monitoring of individuals with abnormal BMI, especially those who are underweight.
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Affiliation(s)
- Emma Raymond
- Department of Medical Epidemiology and Biostatistics, Karolinska Institutet, Stockholm, Sweden
| | | | - Anna K Dahl Aslan
- Department of Medical Epidemiology and Biostatistics, Karolinska Institutet, Stockholm, Sweden.,Institute of Gerontology and Aging Research Network - Jönköping (ARN-J), School of Health and Welfare, Jönköping University, Sweden
| | - Deborah Finkel
- Institute of Gerontology and Aging Research Network - Jönköping (ARN-J), School of Health and Welfare, Jönköping University, Sweden.,Department of Psychology, Indiana University Southeast, New Albany
| | - Malin Ericsson
- Department of Medical Epidemiology and Biostatistics, Karolinska Institutet, Stockholm, Sweden
| | - Sara Hägg
- Department of Medical Epidemiology and Biostatistics, Karolinska Institutet, Stockholm, Sweden
| | - Nancy L Pedersen
- Department of Medical Epidemiology and Biostatistics, Karolinska Institutet, Stockholm, Sweden
| | - Juulia Jylhävä
- Department of Medical Epidemiology and Biostatistics, Karolinska Institutet, Stockholm, Sweden
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Buchan SA, Daneman N, Wang J, Wilson SE, Garber G, Wormsbecker AE, Antoniou T, Deeks SL. Herpes zoster in older adults in Ontario, 2002-2016: Investigating incidence and exploring equity. PLoS One 2021; 16:e0246086. [PMID: 33571224 PMCID: PMC7877748 DOI: 10.1371/journal.pone.0246086] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/12/2020] [Accepted: 01/12/2021] [Indexed: 11/18/2022] Open
Abstract
Older adults are at increased risk of herpes zoster (HZ) and post-herpetic neuralgia (PHN) and HZ vaccines are available to help prevent infection. The objective of our study was to provide updated data on incidence of HZ and PHN related to clinical and demographic factors in older adults to inform immunization practices. We conducted a population-based, retrospective cohort study and included all cases of HZ seen in outpatient, emergency department, and hospital settings for adults aged 65 years and over between April 1, 2002 to August 31, 2016 in Ontario, Canada. We calculated the incidence of HZ and PHN, and estimated the proportion within each subgroup that developed PHN. We also assessed incidence by neighbourhood-level income quintile before and after the availability of vaccine for private purchase. The average annual incidence of HZ in any setting was 59.0 per 10,000 older adults, with higher incidence in outpatient as opposed to hospital settings. Incidence was higher in the oldest age groups, females, and those classified as immunocompromised or frail. Relative to the pre-vaccine era, the disparities in incidence of HZ by neighbourhood-level income increased, with higher rates of HZ and PHN seen in those residing in lower income quintiles. Additional prevention efforts should be targeted toward adults who are immunocompromised, frail, and those living in lower socioeconomic quintiles. Future work should assess the impact of the zoster vaccine program with a particular focus on equity in the publicly-funded era.
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Affiliation(s)
- Sarah A. Buchan
- Health Protection, Public Health Ontario, Toronto, Ontario, Canada
- Populations and Public Health, ICES, Toronto, Ontario, Canada
- Dalla Lana School of Public Health, University of Toronto, Toronto, Ontario, Canada
- * E-mail:
| | - Nick Daneman
- Health Protection, Public Health Ontario, Toronto, Ontario, Canada
- Populations and Public Health, ICES, Toronto, Ontario, Canada
- Sunnybrook Research Institute, Toronto, Ontario, Canada
- Division of Infectious Diseases, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
- Department of Medicine, University of Toronto, Toronto, Ontario, Canada
- Institute for Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada
| | - Jun Wang
- Health Protection, Public Health Ontario, Toronto, Ontario, Canada
- Populations and Public Health, ICES, Toronto, Ontario, Canada
| | - Sarah E. Wilson
- Health Protection, Public Health Ontario, Toronto, Ontario, Canada
- Populations and Public Health, ICES, Toronto, Ontario, Canada
- Dalla Lana School of Public Health, University of Toronto, Toronto, Ontario, Canada
| | - Gary Garber
- Health Protection, Public Health Ontario, Toronto, Ontario, Canada
- Department of Medicine, University of Toronto, Toronto, Ontario, Canada
- Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
- Department of Medicine, University of Ottawa, Ottawa, Ontario, Canada
| | - Anne E. Wormsbecker
- Unity Health Toronto, Toronto, Ontario, Canada
- Department of Pediatrics, Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Tony Antoniou
- Populations and Public Health, ICES, Toronto, Ontario, Canada
- Unity Health Toronto, Toronto, Ontario, Canada
- Li Ka Shing Knowledge Institute, St. Michael’s Hospital, Toronto, Ontario
- Department of Family and Community Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Shelley L. Deeks
- Health Protection, Public Health Ontario, Toronto, Ontario, Canada
- Dalla Lana School of Public Health, University of Toronto, Toronto, Ontario, Canada
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Pisano C, Polisano D, Balistreri CR, Altieri C, Nardi P, Bertoldo F, Trombetti D, Asta L, Ferrante MS, Buioni D, Foti C, Ruvolo G. Role of Cachexia and Fragility in the Patient Candidate for Cardiac Surgery. Nutrients 2021; 13:nu13020517. [PMID: 33562449 PMCID: PMC7915488 DOI: 10.3390/nu13020517] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2020] [Revised: 01/27/2021] [Accepted: 01/29/2021] [Indexed: 12/16/2022] Open
Abstract
Frailty is the major expression of accelerated aging and describes a decreased resistance to stressors, and consequently an increased vulnerability to additional diseases in elderly people. The vascular aging related to frail phenotype reflects the high susceptibility for cardiovascular diseases and negative postoperative outcomes after cardiac surgery. Sarcopenia can be considered a biological substrate of physical frailty. Malnutrition and physical inactivity play a key role in the pathogenesis of sarcopenia. We searched on Medline (PubMed) and Scopus for relevant literature published over the last 10 years and analyzed the strong correlation between frailty, sarcopenia and cardiovascular diseases in elderly patient. In our opinion, a right food intake and moderate intensity resistance exercise are mandatory in order to better prepare patients undergoing cardiac operation.
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Affiliation(s)
- Calogera Pisano
- Department of Cardiac Surgery, Tor Vergata University Hospital, 00133 Rome, Italy; (C.A.); (P.N.); (F.B.); (D.T.); (L.A.); (M.S.F.); (D.B.); (G.R.)
- Correspondence: ; Tel.: +39-328-329-7692; Fax: +39-(06)-2090-3538
| | - Daniele Polisano
- Physical and Rehabilitation Medicine, Tor Vergata University of Rome, 00133 Rome, Italy; (D.P.); (C.F.)
| | - Carmela Rita Balistreri
- Department of Biomedicine, Neuroscience and Advanced Diagnostics (Bi.N.D.), University of Palermo, 90133 Palermo, Italy;
| | - Claudia Altieri
- Department of Cardiac Surgery, Tor Vergata University Hospital, 00133 Rome, Italy; (C.A.); (P.N.); (F.B.); (D.T.); (L.A.); (M.S.F.); (D.B.); (G.R.)
| | - Paolo Nardi
- Department of Cardiac Surgery, Tor Vergata University Hospital, 00133 Rome, Italy; (C.A.); (P.N.); (F.B.); (D.T.); (L.A.); (M.S.F.); (D.B.); (G.R.)
| | - Fabio Bertoldo
- Department of Cardiac Surgery, Tor Vergata University Hospital, 00133 Rome, Italy; (C.A.); (P.N.); (F.B.); (D.T.); (L.A.); (M.S.F.); (D.B.); (G.R.)
| | - Daniele Trombetti
- Department of Cardiac Surgery, Tor Vergata University Hospital, 00133 Rome, Italy; (C.A.); (P.N.); (F.B.); (D.T.); (L.A.); (M.S.F.); (D.B.); (G.R.)
| | - Laura Asta
- Department of Cardiac Surgery, Tor Vergata University Hospital, 00133 Rome, Italy; (C.A.); (P.N.); (F.B.); (D.T.); (L.A.); (M.S.F.); (D.B.); (G.R.)
| | - Maria Sabrina Ferrante
- Department of Cardiac Surgery, Tor Vergata University Hospital, 00133 Rome, Italy; (C.A.); (P.N.); (F.B.); (D.T.); (L.A.); (M.S.F.); (D.B.); (G.R.)
| | - Dario Buioni
- Department of Cardiac Surgery, Tor Vergata University Hospital, 00133 Rome, Italy; (C.A.); (P.N.); (F.B.); (D.T.); (L.A.); (M.S.F.); (D.B.); (G.R.)
| | - Calogero Foti
- Physical and Rehabilitation Medicine, Tor Vergata University of Rome, 00133 Rome, Italy; (D.P.); (C.F.)
| | - Giovanni Ruvolo
- Department of Cardiac Surgery, Tor Vergata University Hospital, 00133 Rome, Italy; (C.A.); (P.N.); (F.B.); (D.T.); (L.A.); (M.S.F.); (D.B.); (G.R.)
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Gedfew M, Ayenew T, Mengst B, Yirga T, Zelalem M, Worku Y, Liknaw T. <p>Incidence and Predictors of Congestive Heart Failure Among Hemodialysis Patients at Felege Hiote Referral Hospital, Northwest Ethiopia, 2020: Retrospective Cohort Study</p>. RESEARCH REPORTS IN CLINICAL CARDIOLOGY 2020. [DOI: 10.2147/rrcc.s274942] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
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Sanaiha Y, Ziaeian B, Antonios JW, Kavianpour B, Anousheh R, Benharash P. Intraaortic Balloon Pump vs Peripheral Ventricular Assist Device Use in the United States. Ann Thorac Surg 2020; 110:1997-2005. [PMID: 32454014 PMCID: PMC7687352 DOI: 10.1016/j.athoracsur.2020.03.129] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/28/2019] [Revised: 02/26/2020] [Accepted: 03/31/2020] [Indexed: 11/21/2022]
Abstract
BACKGROUND The objective of this study was to characterize practical use trends and outcomes for intraaortic balloon pump (IABP) and percutaneous left ventricular assist device (pVAD) use in cardiogenic shock at a national level. METHODS An analysis of all adult patients admitted nonelectively for cardiogenic shock from January 2008 through December 2017 was performed using the National Inpatient Sample. Trends of inpatient IABP and pVAD use were analyzed using survey-weighted estimates and the modified Cochran-Armitage test for significance. Multivariable regression models and inverse probability of treatment weights were used to perform risk-adjusted analyses of pVAD mortality, a composite of adverse events (AE), and resource use, with IABP as reference. RESULTS Of an estimated 774,310 patients admitted with cardiogenic shock, 143,051 received a device: IABP, 127,792 (16.5%); or pVAD, 15,259 (2.0%). IABP use decreased (23.8% to 12.7%; P for trend <.001), whereas pVAD implantation increased significantly during the study period (0.2% to 4.5%; P for trend <.001). Inverse probability of treatment weights demonstrated significantly higher odds of mortality with pVAD (odds ratio, 1.9; 95% confidence interval, 1.7 to 2.2), but not AE (odds ratio, 1.1; 95% confidence interval, 0.96 to 1.27), compared with IABP. After risk adjustment, pVAD use was associated with an additional $15,202 (P < .001) in cost for survivors and $29,643 for nonsurvivors (P < .001). CONCLUSIONS Over the study period, the rate of pVAD use for cardiogenic shock significantly increased. Compared with IABP, pVAD use was associated with increased mortality, higher costs, and several AEs. Multi-institutional clinical trials with rigorous inclusion criteria are warranted to evaluate the clinical utility of pVADs in the modern era.
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Affiliation(s)
- Yas Sanaiha
- Cardiovascular Outcomes Research Laboratories (CORELAB), David Geffen School of Medicine, University of California, Los Angeles, Los Angeles, California
| | - Boback Ziaeian
- Division of Cardiology, David Geffen School of Medicine at University of California, Los Angeles, Los Angeles, California; Division of Cardiology, Veterans Administration Greater Los Angeles Healthcare System, Los Angeles, California
| | - James W Antonios
- Cardiovascular Outcomes Research Laboratories (CORELAB), David Geffen School of Medicine, University of California, Los Angeles, Los Angeles, California
| | - Behdad Kavianpour
- Cardiovascular Outcomes Research Laboratories (CORELAB), David Geffen School of Medicine, University of California, Los Angeles, Los Angeles, California
| | - Ramtin Anousheh
- Division of Cardiology, David Geffen School of Medicine at University of California, Los Angeles, Los Angeles, California
| | - Peyman Benharash
- Cardiovascular Outcomes Research Laboratories (CORELAB), David Geffen School of Medicine, University of California, Los Angeles, Los Angeles, California; Division of Cardiac Surgery, University of California, Los Angeles, Los Angeles, California.
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Sun LY, Mielniczuk LM, Liu PP, Beanlands RS, Chih S, Davies R, Coutinho T, Lee DS, Austin PC, Bader Eddeen A, Tu JV. Sex-specific temporal trends in ambulatory heart failure incidence, mortality and hospitalisation in Ontario, Canada from 1994 to 2013: a population-based cohort study. BMJ Open 2020; 10:e044126. [PMID: 33243819 PMCID: PMC7692840 DOI: 10.1136/bmjopen-2020-044126] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
OBJECTIVES To examine the temporal trends in mortality and heart failure (HF) hospitalisation in ambulatory patients following a new diagnosis of HF. DESIGN Retrospective cohort study SETTING: Outpatient PARTICIPANTS: Ontario residents who were diagnosed with HF in an outpatient setting between 1994 and 2013. PRIMARY AND SECONDARY OUTCOME MEASURES The primary outcome was all-cause mortality within 1 year of diagnosis and the secondary outcome was HF hospitalisation within 1 year. Risks of mortality and hospitalisation were calculated using the Kaplan-Meier method and the relative hazard of death was assessed using multivariable Cox proportional hazard models. RESULTS A total of 352 329 patients were studied (50% female). During the study period, there was a greater decline in age standardised 1-year mortality rates (AMR) in men (33%) than in women (19%). Specifically, female AMR at 1 year was 10.4% (95% CI 9.1% to 12.0%) in 1994 and 8.5% (95% CI 7.5% to 9.5%) in 2013, and male AMR at 1 year was 12.3% (95% CI 11.1% to 13.7%) in 1994 and 8.3% (95% CI 7.5% to 9.1%) in 2013. Conversely, age standardised HF hospitalisation rates declined in men (11.4% (95% CI 10.1% to 12.9%) in 1994 and 9.1% (95% CI 8.2% to 10.1%) in 2013) but remained unchanged in women (9.7% (95% CI 8.3% to 11.3%) in 1994 and 9.8% (95% CI 8.6% to 11.0%) in 2013). CONCLUSION Among patients with HF over a 20-year period, there was a greater improvement in the prognosis of men compared with women. Further research should focus on the determinants of this disparity and ways to reduce this gap in outcomes.
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Affiliation(s)
- Louise Y Sun
- Division of Cardiac Anesthesiology, Department of Anesthesiology and Pain Medicine, University of Ottawa Heart Institute, Ottawa, Ontario, Canada
- Cardiovasulcar Research Program, ICES (formerly the Institute for Clinical Evaluative Sciences), Toronto, Ontario, Canada
- School of Epidemiology and Public Health, University of Ottawa, Ottawa, Ontario, Canada
| | - Lisa M Mielniczuk
- Division of Cardiology, Department of Medicine, University of Ottawa Heart Institute, Ottawa, Ontario, Canada
| | - Peter P Liu
- Division of Cardiology, Department of Medicine, University of Ottawa Heart Institute, Ottawa, Ontario, Canada
| | - Rob S Beanlands
- Division of Cardiology, Department of Medicine, University of Ottawa Heart Institute, Ottawa, Ontario, Canada
| | - Sharon Chih
- Division of Cardiology, Department of Medicine, University of Ottawa Heart Institute, Ottawa, Ontario, Canada
| | - Ross Davies
- Division of Cardiology, Department of Medicine, University of Ottawa Heart Institute, Ottawa, Ontario, Canada
| | - Thais Coutinho
- Division of Cardiology, Department of Medicine, University of Ottawa Heart Institute, Ottawa, Ontario, Canada
- Division of Prevention and Rehabilitation, University of Ottawa Heart Institute, Ottawa, Ontario, Canada
| | - Douglas S Lee
- Cardiovasulcar Research Program, ICES (formerly the Institute for Clinical Evaluative Sciences), Toronto, Ontario, Canada
- Peter Munk Cardiac Centre, University Health Network, University of Toronto, Toronto, Ontario, Canada
| | - Peter C Austin
- Cardiovasulcar Research Program, ICES (formerly the Institute for Clinical Evaluative Sciences), Toronto, Ontario, Canada
| | - Anan Bader Eddeen
- Cardiovasulcar Research Program, ICES (formerly the Institute for Clinical Evaluative Sciences), Toronto, Ontario, Canada
| | - Jack V Tu
- Cardiovasulcar Research Program, ICES (formerly the Institute for Clinical Evaluative Sciences), Toronto, Ontario, Canada
- Sunnybrook Schulich Heart Centre, University of Toronto, Toronto, Ontario, Canada
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Abstract
OBJECTIVE To examine the prevalence of frailty in surgical patients and determine whether age and sex modify the relationship between frailty and long-term mortality. BACKGROUND Frailty is a complex and prevalent clinical syndrome. The cardiac surgery literature consists mostly of small, single-center studies, and the epidemiology of frailty remains to be fully elucidated in a real-world surgical population. METHODS This retrospective cohort study included patients who underwent coronary artery bypass grafting, and/or aortic, mitral or tricuspid valve surgery in Ontario, Canada, between 2008 and 2016. The primary outcome was all-cause mortality. Survival probabilities were calculated using the Kaplan-Meier method, and the association of covariates with the hazard of death was assessed using multivariable Cox proportional hazard models. Frailty was assessed using the Johns Hopkins Adjusted Clinical Groups frailty-defining diagnoses indicator. RESULTS Of 72,824 patients, 11,685 (16%) were frail. At median 5 ± 2 years of follow-up, 2921 (25.0%) frail patients and 8637 (14.1%) non-frail patients had died [adjusted hazard ratio 1.60; 95% confidence interval (CI), 1.53-1.68]. The adjusted hazard ratio was highest in patients who underwent isolated mitral (2.18; 95% CI, 1.71-2.77) and mitral + aortic valve surgery (1.85; 95% CI, 1.33-2.58) and lowest after coronary artery bypass grafting + mitral valve surgery (1.38; 95% CI, 1.11-1.70). Age, but not sex, modified the effect of frailty on mortality; such that the rate of death decreased linearly with increasing patient age. CONCLUSIONS We observed a high prevalence of frailty in patients undergoing cardiac surgery, and a statistically significant association between frailty and long-term mortality after cardiac procedures. Importantly, the rate of death was inversely proportional to age, such that frailty had a stronger adverse impact on younger patients. Our findings highlight the need to incorporate frailty into the preoperative risk stratification and investigate strategies to support younger patients who are frail.
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Sex differences after coronary artery bypass grafting with a second arterial conduit. J Thorac Cardiovasc Surg 2020; 163:686-695.e10. [PMID: 32493659 DOI: 10.1016/j.jtcvs.2020.04.058] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/05/2019] [Revised: 04/13/2020] [Accepted: 04/15/2020] [Indexed: 11/23/2022]
Abstract
OBJECTIVES Double arterial conduit use during coronary artery bypass grafting is associated with improved clinical outcomes compared with single arterial conduits in the general population. However, the sex-specific outcomes of this strategy remain unknown and are needed to inform sex-specific revascularization guidelines. METHODS We conducted a population-based, retrospective cohort study of all Ontarians who underwent primary isolated coronary artery bypass grafting with single arterial conduits or double arterial conduits between October 2008 and September 2017. The primary outcome was all-cause mortality. Secondary outcomes included major adverse cardiac and cerebrovascular events, defined as a composite of myocardial infarction, heart failure hospitalization, repeat revascularization, and stroke. We used inverse probability of treatment weighting to account for group imbalances. RESULTS A total of 9135 women and 36,748 men underwent coronary artery bypass grafting. At 30 days, there was no between-group difference in mortality or major adverse cardiac and cerebrovascular events in men. However, among women, a double arterial conduit was associated with an increased rate of 30-day death (hazard ratio, 1.48; 95% confidence interval, 1.23-1.79) and major adverse cardiac and cerebrovascular events (hazard ratio, 1.32; 95% confidence interval, 1.14-1.51). The risk of medium-term mortality with double arterial conduits was less in men (hazard ratio, 0.88; 95% confidence interval, 0.84-0.92) and women (hazard ratio, 0.87; 95% confidence interval, 0.81-0.94), as was the medium-term risk of major adverse cardiac and cerebrovascular events (hazard ratio, 0.91; 95% confidence interval, 0.87-0.94) [men]; hazard ratio, 0.91; 95% confidence interval, 0.86-0.97) [women]). The incremental improvement in 9-year survival was 4.0% in women with a double arterial conduit and 0.9% in men. CONCLUSIONS Double arterial conduit is associated with better medium-term survival and cardiovascular outcomes in both sexes. Double arterial conduits are associated with increased perioperative risk in women, but the medium-term benefit is greater than in men.
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Lowenstern A, Wang TY. Rethinking Cognitive Impairment in the Management of Older Patients With Cardiovascular Disease. J Am Heart Assoc 2019; 8:e011968. [PMID: 30773969 PMCID: PMC6405686 DOI: 10.1161/jaha.119.011968] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
See Article by Gu et al
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Affiliation(s)
- Angela Lowenstern
- 1 Duke Clinical Research Institute Durham NC.,2 Division of Cardiology Department of Medicine Duke University School of Medicine Durham NC
| | - Tracy Y Wang
- 1 Duke Clinical Research Institute Durham NC.,2 Division of Cardiology Department of Medicine Duke University School of Medicine Durham NC
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