Let Us Talk About Moving: Reframing the Exercise and Physical Activity Discussion

Noncommunicable and chronic disease are interchangeable terms. According to the World Health Organization, "they are of long duration and generally slow progression. The 4 main types of chronic diseases are cardiovascular diseases (ie, heart attacks and stroke), cancers, chronic respiratory diseases (such as chronic obstructive pulmonary disease and asthma), and diabetes." We have known about the benefits of physical activity (PA) for thousands of years. Perhaps our approach, from public health messaging to the individual clinical encounter, as to how PA and exercise are discussed and prescribed can be improved upon, with the ultimate goal of increasing the likelihood that an individual moves more; ultimately moving more should be the goal. In fact, there is an incongruence between the evidence for the benefits of physical movement and how we message and integrate PA and exercise guidance into health care, if it is discussed at all. Specifically, evidence clearly indicates any migration away from the sedentary phenotype toward a movement phenotype is highly beneficial. As we necessarily move to a proactive, preventive healthcare model, we must reconceptualize how we evaluate and treat conditions that pose the greatest threat, namely chronic disease; there is a robust body of evidence supporting the premise of movement as medicine. The purpose of this perspective paper is to propose an alternate model for promoting, assessing, discussing, and prescribing physical movement.

Mortality in isolated coronary artery bypass surgery in elderly patients. A retrospective analysis over 14 years

INTRODUCTION

We aim to describe our experience in coronary artery bypass graft in elderly patients older than 80 years and assess the associated risk and predictors of mortality in this subgroup.

MATERIAL AND METHOD

From January 1999 to June 2013, 3097 patients underwent consecutive coronary artery bypass graft surgery. Patients aged over 80 years were identified. Multivariate survival analysis using Cox's regression model was performed.

RESULTS

We identified 99 patients older than 80 years (80-group; mean age 82±3.5 years) and 2957 younger than 80 years (control group) (mean age 64.2±9.7 years). Additive EuroSCORE was 8.4±4.8 and 4.6±4.6 (P<.001) in the 80-group vs. control group, respectively. Off-pump coronary artery bypass graft was performed in 79.6 vs. 41.6% (P<.001) in the 80-group vs. the control group. respectively. There was significantly higher 30 day-mortality in the 80-group, 11.2 vs. 3.3%, respectively (P<.001). Patients in the 80-group underwent reintervention for bleeding more frequently (9.2 vs. 2.9%; P=.001) and had a higher incidence of major cardiovascular complications than the control group (6.1 vs. 2.1%; P=.001). Independent predictors of mortality for the 80-group were: reoperation for bleeding (HR 5.7; 95% CI 1.6-19.5) and cardiovascular complications (HR 3.7; 95% CI 1.1-12.2). The mean follow-up was 6.3±4.2 years for the octogenarian group. The cumulative survival of these patients was 65.7% during the study period.

CONCLUSION

Coronary artery bypass graft is performed preferably in patients over 80 years old under the off-pump procedure. Mortality is higher in this group of patients probably related to a higher incidence of cardiovascular complications and reintervention for bleeding in the immediate postoperative period.

EuroSCORE II with SYNTAX score to assess risks of coronary artery bypass grafting outcomes

OBJECTIVES

We evaluated the usefulness of the combination of European System for Cardiac Operative Risk Evaluation score (EuroSCORE II) and SYNergy between percutaneous intervention with TAXus drug-eluting stents and cardiac surgery (SYNTAX) score in predicting risks associated with early and late outcomes after coronary artery bypass grafting (CABG).

METHODS

Between January 2010 and April 2012, 412 patients underwent isolated CABG at our institution. EuroSCORE II and SYNTAX score were calculated retrospectively, and their ability to predict early and long-term outcomes was evaluated. Patients were divided into four groups according to median EuroSCORE II and SYNTAX score: Group 1, low EuroSCORE II, low SYNTAX (n=103); Group 2, low EuroSCORE II, high SYNTAX (n=103); Group 3, high EuroSCORE II, low SYNTAX (n=99); and Group 4, high EuroSCORE II, high SYNTAX (n=107).

RESULTS

Operative death was not different among the groups; however, Group 4 had the highest major complication rate of the four groups (0 in Group 1, 2.9% in Group 2, 3.0% in Group 3 and 8.4% in Group 4; P=0.011). Multivariate analyses revealed that both high EuroSCORE II (odds ratio [OR]: 4.154; P=0.030) and high SYNTAX score (OR: 3.988; P=0.035) were independent predictors of postoperative major complications and that high EuroSCORE II was an independent predictor of late mortality (OR: 4.673; P=0.016) but high SYNTAX score was not (OR: 0.808; P=0.662). Actuarial survival rate at 3 years was the lowest in Group 4 (99.0±1.0% in Group 1, 97.7±1.6% in Group 2, 91.9±2.7% in Group 3 and 90.5±4.7% in Group 4; P=0.045).

CONCLUSIONS

The combination of EuroSCORE II and SYNTAX score was useful in predicting early major complications after CABG. In the long term, EuroSCORE II continued to be associated with late mortality, but SYNTAX score did not.

A multicentre Spanish study for multivariate prediction of perioperative in-hospital cerebrovascular accident after coronary bypass surgery: the PACK2 score

OBJECTIVES

To develop a multivariate predictive risk score of perioperative in-hospital stroke after coronary artery bypass grafting (CABG) surgery.

METHOD

A total of 26 347 patients were enrolled from 21 Spanish hospital databases. Logistic regression analysis was used to predict the risk of perioperative stroke (ictus or transient ischaemic attack). The predictive scale was developed from a training set of data and validated by an independent test set, both selected randomly. The assessment of the accuracy of prediction was related to the area under the ROC curve. The variables considered were: preoperative (age, gender, diabetes mellitus, arterial hypertension, previous stroke, cardiac failure and/or left ventricular ejection fraction<40%, non-elective priority of surgery, extracardiac arteriopathy, chronic kidney failure and/or creatininemia≥2 mg/dl and atrial fibrillation) and intraoperative (on/off-pump).

RESULTS

Global perioperative stroke incidence was 1.38%. Non-elective priority of surgery (priority; OR=2.32), vascular disease (arteriopathy; OR=1.37), cardiac failure (cardiac; OR=3.64) and chronic kidney failure (kidney; OR=6.78) were found to be independent risk factors for perioperative stroke in uni- and multivariate models in the training set of data; P<0.0001; AUC=0.77, 95% CI 0.73-0.82. The PACK2 stroke CABG score was established with 1 point for each item, except for chronic kidney failure with 2 points (range 0-5 points); AUC=0.76, 95% CI 0.72-0.80. In patients with PACK2 score≥2 points, off-pump reduced perioperative stoke incidence by 2.3% when compared with on-pump CABG.

CONCLUSIONS

PACK2 risk scale shows good predictive accuracy in the data analysed and could be useful in clinical practice for decision making and patient selection.

Performance of the original EuroSCORE

The European system for cardiac operative risk evaluation (EuroSCORE) is a commonly used risk score for operative mortality following cardiac surgery. We aimed to conduct a systematic review of the performance of the additive and logistic EuroSCORE. A literature search resulted in 67 articles. Studies applying the EuroSCORE on patients undergoing cardiac surgery and which reported early mortality were included. Weighted meta-regression showed that the EuroSCORE overestimated mortality. However, this performance depended on the risk profile of patients: in high-risk patients, the additive model actually underestimated mortality. Discriminative performance was good. Given the poor predictive performance, the EuroSCORE may not be suitable as a tool for patient selection nor for benchmarking.

Impact of incomplete surgical revascularization on survival

Complete revascularization is considered superior to incomplete revascularization (IR), with better long-term survival and a lower rate of reintervention. However, it has yet to be established whether this difference is due directly to IR as a surgical strategy or whether this approach is merely a marker of more severe coronary disease and more rapid progression. We believe that IR is a prognostic marker for a more complex coronary pathology, and adverse effects are probably due to the preoperative condition of the patient. In fact, although IR may negatively affect long-term outcomes, it may be, when wisely chosen, the ideal treatment strategy in selected high-risk patients. IR can derive from a surgical strategy of target vessel revascularization, where the impact of surgery is minimized to reduce perioperative mortality and morbidity, aiming to achieve the best feasible safe revascularization.