Preoperative Frailty Assessment and Outcomes at 6 Months or Later in Older Adults Undergoing Cardiac Surgical Procedures

Abstract

Background Frailty assessment may inform surgical risk and prognosis that are not captured by conventional surgical risk scores. Purpose To evaluate the evidence for various frailty instruments to predict mortality, functional status, or major adverse cardiovascular and cerebrovascular events (MACCE) in older adults undergoing cardiac surgical procedures. Data Sources MEDLINE and EMBASE (without language restrictions), from their inception to May 2, 2016. Study Selection Cohort studies that evaluated the association of frailty with mortality or functional status at ≥6 months in patients aged ≥60 years undergoing major or minimally invasive cardiac surgical procedures. Data Extraction Two reviewers independently extracted study data and assessed study quality. Data Synthesis Mobility, disability, and nutrition were frequently assessed domains of frailty in both types of procedures. In patients undergoing major procedures (N=18388, 8 studies), 9 frailty instruments were evaluated. There was moderate-quality evidence to assess mobility or disability and very-low-to-low-quality evidence to use a multi-component instrument to predict mortality or MACCE. No studies examined functional status. In patients undergoing minimally invasive procedures (N=5177, 17 studies), 13 frailty instruments were evaluated. There was moderate-to-high-quality evidence to assess mobility to predict mortality or functional status. Several multi-component instruments predicted mortality, functional status, or MACCE, but the quality of evidence was low to moderate. Multi-component instruments that measure different frailty domains seemed to outperform single-component instruments. Limitations Heterogeneity of frailty assessment, limited generalizability of multi-component frailty instruments, few validated frailty instruments, and potential publication bias. Conclusions Frailty status, assessed by mobility, disability, and nutritional status, can predict mortality at 6 months or later after major cardiac surgical procedures and functional decline after minimally invasive cardiac surgical procedures. Primary Funding Source National Institute on Aging and National Heart, Lung, and Blood Institute; there was no registration for this review.

Association of Frailty and Long‐Term Survival in Patients Undergoing Coronary Artery Bypass Grafting

“…In addition, the wide range of published prevalence and frailty‐related mortality risk is likely because of the differences in frailty instruments used. A systematic review of 8 studies directly comparing 9 different frailty instruments used in cardiac surgery cohorts noted that the multicomponent instruments provided better mortality risk prediction, despite poorer discrimination than their abbreviated single‐domain counterparts 3. The Johns Hopkins ACG frailty indicator is a comprehensive tool that provides a multidimensional snapshot of a patient's physical status and is able to predict the risk of long‐term mortality in this cohort of patients undergoing CABG.…”

“…Frailty is an emerging concept in perioperative medicine but remains a poorly recognized and poorly investigated syndrome in patients undergoing cardiac surgery 1, 2, 3, 4. It is increasing in prevalence and presents a formidable challenge for clinicians who work to optimize these patients 5.…”

Impact of frailty on outcomes after discharge in older surgical patients: a prospective cohort study

“…Of 25 studies on frailty assessment for prognosis after cardiac surgery, only 2 used the Clinical Frailty Scale, and none used the scale to predict readmission. 13 The handful of prior studies conducted in a surgical setting largely reported adverse prognosis for patients with frailty, but were mostly restricted to specific procedures and short follow-up periods. [23][24][25][26][27] Very few studies have assessed a dose-response relation.…”

“…Alternatively, residual confounding may account for some of the risk observed; however, we adjusted for a variety of clinical and biologic markers, as did multiple prior studies of mortality. 13,24,25 …”

“…6,7 Frailty is a known risk factor for complications, [8][9][10][11] prolonged hospital stay 8,12 and adverse discharge disposition. 8,11 Furthermore, degree of frailty shows a dose-response relation to mortality in both surgical 13 and critically ill 5 patients. However, the impact of frailty on readmission after surgery in older patients has rarely been assessed.…”