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Frailty status may predict mortality in older patients undergoing cardiac surgeries

Assessing frailty before major cardiac surgical procedures or minimally invasive cardiac surgery predicts mortality and functional decline, according to findings published in the Annals of Internal Medicine.

Dae Hyun Kim, MD, MPH, ScD, from Beth Israel Deaconess Medical Center, Boston, and colleagues wrote that the measures would be useful in making informed decisions.

They noted that more than 50% of the 500,000 cardiac surgical procedures performed in the United States each year occur in older adults.

"Because of the high burden of cardiovascular disease and evolution of minimally invasive surgical techniques, this number is expected to rise," Kim and colleagues wrote. "Although older patients may benefit from these procedures, some die or have complications, functional decline, and poor quality of life. Identifying patients who are most or least likely to benefit from surgical procedures remains a significant challenge."

The researchers searched EMBASE and MEDLINE for relevant cohort studies of adults with a mean age of 60 years who had at least 6 months of follow up. Studies could measure frailty by any measure of physical function, including disability, mobility, muscle strength, balance, nutrition, physical activity or exhaustion. Surgical procedures included coronary artery bypass grafting (CABG), open valve surgery, or transcatheter aortic valve replacement (TAVR).

Results showed moderate-quality evidence for assessing disability or mobility to predict mortality or major adverse cardiovascular and cerebrovascular events in patients undergoing major procedures (n = 18,388; eight studies). There was moderate- to high-quality evidence for assessing mobility to predict functional status or mortality in patients undergoing minimally invasive procedures (n = 5,177; 17 studies).

"Clinicians should attempt to classify patients into three groups: extreme-risk patients, whose predicted health status after the procedure is unlikely to be meaningfully better than it would without the procedure; high-risk patients, whose predicted health status after the procedure is likely to be better than it would be without the procedure, albeit with a high yet not prohibitive risk for harms; and low-risk patients, who are likely to benefit from the procedure with a low risk for harms," they wrote. "Health status should not be confined to the risk for short-term complications or death; functional status may be as important, depending on the patient's values."

Kim and colleagues recommended using the following tests: gait speed, Timed Up and Go test, the Clinical Frailty Scale or self-reported nutritional status, disability and mobility.

In an accompanying editorial, Victoria L. Tang, MD, MAS, and Kenneth Covinsky, MD, MPH, from the University of California, San Francisco, wrote that assessing frailty will lead to discussion regarding goals of care.

"This important finding supports frailty assessment in older adults considering surgery," Tang and Covinsky wrote. "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). 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." – by Chelsea Frajerman Pardes

Disclosures: Kim reports personal fees from the Alosa Foundation and grants from the National Institute on Aging, American Federation for Aging Research, John A. Hartford Foundation, and Atlantic Philanthropies, outside the submitted work. Please see the full study for a complete list of all other authors' relevant financial disclosures.