Frailty assessments may help predict outcomes after cardiac surgery in older adults
Frailty status as assessed by mobility, disability, and nutritional status may predict death at 6 months or more after major cardiac surgery and functional decline after minimally invasive cardiac surgery.
Frailty as assessed by mobility, disability, and nutritional status may help predict outcomes after major and minimally invasive cardiac surgery in older patients, according to a recent systematic review.
Researchers performed a systematic review to evaluate the evidence supporting several frailty instruments used to predict outcomes in older adults having cardiac surgery. MEDLINE and EMBASE were searched without language restrictions through May 2, 2016. Cohort studies were included if they looked at the association between frailty and death or functional status (as assessed by Activities of Daily Living, the Duke Activity Status Index, the Kansas City Cardiomyopathy Questionnaire, or New York Heart Association class) at 6 months or longer in patients at least 60 years of age after major or minimally invasive cardiac surgery. Coronary artery bypass grafting and open-valve surgery were classified as major procedures, and transcatheter aortic valve replacement was classified as minimally invasive surgery.
Results were published online Aug. 23 by Annals of Internal Medicine.
For both major and minor surgery, mobility, disability, and nutrition were frequently assessed domains of frailty. Nine frailty instruments were evaluated in 18,388 patients from 8 studies who were undergoing major cardiac surgery. Mean age of patients ranged from 62 to 79 years. In this group, moderate-quality evidence supported assessment of mobility or disability, and very low- to low-quality evidence supported use of a multicomponent instrument to predict death or major adverse cardiovascular and cerebrovascular events (MACCEs). None of the 8 studies examined functional status in major cardiac surgery patients.
Thirteen frailty instruments were evaluated in 17 studies of 5,177 patients undergoing minimally invasive procedures. Mean age of patients ranged from 79 to 86 years. Moderate- to high-quality evidence supported assessment of mobility to predict death or functional status. Although several multicomponent instruments predicted death, functional status, or MACCEs in this group, the evidence was low- or moderate-quality.
The researchers acknowledged that the frailty assessments in the studies were heterogeneous and that few frailty instruments have been validated. In addition, they noted that multicomponent frailty instruments had limited generalizability, since they were evaluated in study samples from single centers, and that publication bias was possible. However, they concluded that frailty status as assessed by mobility, disability, and nutritional status may predict death at 6 months or more after major cardiac surgery and functional decline after minimally invasive cardiac surgery.
The authors recommended that clinicians should try to classify patients preoperatively into 3 groups:
- extreme risk, with predicted health status after the procedure unlikely to be meaningfully better than without the procedure;
- high risk, with predicted health status after the procedure likely better than without the procedure, though with a high risk for harm; and
- low risk, with likely benefit from the procedure but low risk for harm.
They also noted that functional status may be as important to patients as risk for short-term complications or death and that this should factor into assessments.
An accompanying editorial said the review shows that frailty status is a strong predictor of longer-term mortality and supports frailty assessment in older adults who are considering surgery.
“In addition, to inform surgical decision making for both patients and clinicians, we must assess the effects of frailty on patient-centered outcomes (such as quality of life, function, and cognition),” the editorialists wrote. “Once the decision to have surgery is made, we may better prepare patients and their family members for the possible outcomes and provide needed support, possibly including palliative care. By identifying frailty, we can improve care for our older surgical patients.”