Influence of Preoperative Frailty on Health-Related Quality of Life After Cardiac Surgery

doi:10.1016/j.athoracsur.2018.12.028

The Annals of Thoracic Surgery

Volume 108, Issue 1, July 2019, Pages 23-29

Presented at the Annual Meeting of the Spanish Society of Cardiovascular and Thoracic Surgery Congress, Murcia, Spain, May 30–June 2, 2018.

https://doi.org/10.1016/j.athoracsur.2018.12.028 Get rights and content

Background

Frailty has emerged as one of the main predictors of worse outcomes after cardiac surgery, but scarce evidence is available about its influence on postoperative quality of life. Whether frail patients may improve their quality of life or not after the surgical procedure is a matter that still remains unclear.

Methods

This observational and multicenter cohort study was conducted in 3 university-affiliated hospitals of three different regions of Spain (Madrid, Asturias, and Canary Islands). Patients were categorized into three ordinal levels of frailty (frail, prefrail, robust) using the Fried, FRAIL (fatigue, resistance, ambulation, illnesses, and loss of weight) scale, and Clinical Frailty Scale frailty scales. We analyzed the changes on health-related quality-of-life for each level of frailty using the EuroQoL 5-Dimension 5 Level questionnaire before and 6 months after the operation.

Results

The study included 137 patients, and 109 completed the 6-month follow-up. Median age of the entire cohort was 78 years (interquartile interval, 72 to 83 years). Frailty prevalence varied between 10% and 29%, depending on which scale was used. There was a statistically significant linear trend in the incidence of death or major morbidity among the different levels of frailty. On one hand, robust patients did not show significant changes in their previously high score of quality of life during follow-up. On the other hand, frail and prefrail patients significantly improved their scores after the operation. These results were comparable regardless the scale used for frailty assessment.

Conclusions

Frail and prefrail patients have a significant improvement in their quality of life 6 months after their cardiac operation, and they have a proportionally greater increase in their postoperative health-related quality of life scores than robust patients.

Visual Abstract

Section snippets

Patient Population and Study Design

This prospective, observational, and multicenter cohort study was conducted in 3 university-affiliated tertiary hospitals of three regions of Spain (Madrid, Asturias, and Canary Islands) between April 2015 and December 2016. The Institutional Research Ethics Committees at each of the participating hospitals approved the implementation of this study, and every patient provided signed informed consent.

All patients aged 70 years or older, who were scheduled for an elective cardiac surgical

Results

The study included 137 patients, and 109 completed the 6-month follow-up. During the study period, 12 patients died (8.8%) and 16 were lost to follow-up. The enrollment flowchart is shown in Figure 1.

Frailty prevalence varied between 10% and 29%, depending on which scale was used for the assessment (Fig 2). Baseline patient characteristics are summarized in Table 1. Supplemental Table 1 includes an analysis of changes in HRQoL for the 109 patients who completed the follow-up. Figure 3 shows the

Comment

Although there is a general agreement that good early and midterm outcomes can be achieved after a cardiac operation even in older patients 22, 23, 24, 25, 26, the effect that preoperative frailty might have on the postoperative quality of life has been poorly studied 2, 11, 27. In the present study, we analyzed the changes in HRQoL according to the preoperative frailty status. The main finding is that frail patients significantly improved their diminished quality of life after their operation.

References (34)

J.S. Rumsfeld
Valve surgery in the elderly: question of quality (of life)?
J Am Coll Cardiol
(2003)
J. Lytwyn et al.
The impact of frailty on functional survival in patients 1 year after cardiac surgery
J Thorac Cardiovasc Surg
(2017)
J. Chikwe et al.
Frailty: the missing element in predicting operative mortality
Semin Thorac Cardiovasc Surg
(2010)
J. Afilalo et al.
Frailty in Older Adults Undergoing Aortic Valve Replacement: the FRAILTY-AVR Study
J Am Coll Cardiol
(2017)
A. Clegg et al.
Frailty in elderly people
Lancet
(2013)
A. Sepehri et al.
The impact of frailty on outcomes after cardiac surgery: a systematic review
J Thorac Cardiovasc Surg
(2014)
M. Oppe et al.
A program of methodological research to arrive at the new international EQ-5D-5L valuation protocol
Value Health
(2014)
M.E. Charlson et al.
A new method of classifying prognostic comorbidity in longitudinal studies: development and validation
J Chronic Dis
(1987)
H. Luckraz et al.
Preserved quality of life in octogenarians at early, mid, and late follow-up intervals irrespective of cardiac procedure
Semin Thorac Cardiovasc Surg
(2016)
R.K. Ghanta et al.
Long-term survival and quality of life justify cardiac surgery in the very elderly patient
Ann Thorac Surg
(2011)

J.E. Morley et al.

A simple frailty questionnaire (FRAIL) predicts outcomes in middle aged African Americans

J Nutr Health Aging

(2012)

S.H. Sündermann et al.

Frailty is a predictor of short-and mid-term mortality after elective cardiac surgery independently of age

Interact Cardiovasc Thorac Surg

(2014)

D.H. Lee et al.

Frail patients are at increased risk for mortality and prolonged institutional care after cardiac surgery

Circulation

(2010)

L.P. Fried et al.

Frailty in older adults: evidence for a phenotype

J Gerontol A Biol Sci Med Sci

(2001)

T. Beggs et al.

Frailty and perioperative outcomes: a narrative review

Can J Anaesth J Can Anesth

(2015)

B.R. Kotajarvi et al.

The impact of frailty on patient-centered outcomes following aortic valve replacement

J Gerontol A Biol Sci Med Sci

(2017)

K. Rockwood et al.

A global clinical measure of fitness and frailty in elderly people

CMAJ

(2005)

Cited by (19)

Estimated prevalence of frailty and prefrailty in patients undergoing coronary artery or valvular surgeries/procedures: A systematic review and proportional meta-analysis
2024, Ageing Research Reviews
The aging population has led to an increasing number of older patients undergoing cardiac surgeries/procedures. Frailty and prefrailty have emerged as important prognostic indicators among these patients. This proportional meta-analysis estimated the prevalence of frailty and prefrailty among patients undergoing cardiac surgery.
We searched seven electronic databases for observational studies that used validated measure(s) of frailty and reported prevalence data on frailty and/or prefrailty in older patients undergoing coronary artery or valvular surgeries or transcatheter procedures. Meta-analyses were performed using a random-effects model.
One hundred and one articles involving 626,863 patients were included. The pooled prevalence rates of frailty and prefrailty were 28% (95% confidence interval [CI]: 23%–33%) and 40% (95% CI: 31%–50%), respectively, for patients scheduled for open-heart surgeries and 40% (95% CI: 36%–45%) and 43% (95% CI: 34%–53%), respectively, for patients undergoing transcatheter procedures. Frailty measured using a multidimensional approach identified a higher proportion of frail patients when compared with measures solely focused on physical frailty. Older age, female sex, and lower body mass index and hemoglobin concentrations were significantly associated with higher frailty prevalence. Moreover, countries with higher gross domestic product spent on healthcare exhibited a higher frailty prevalence.
Frailty represents a considerable health challenge among patients undergoing cardiac surgeries/procedures. Routine screening for frailty should be considered during perioperative care planning.
The prognostic impacts of frailty on clinical and patient-reported outcomes in patients undergoing coronary artery or valvular surgeries/procedures: A systematic review and meta-analysis
2023, Ageing Research Reviews
Frailty is emerging as an important prognostic indicator for patients undergoing cardiac surgeries/procedures. We sought to evaluate the prognostic and differential impacts of frailty on patients undergoing coronary artery or valvular surgical procedures of different levels of invasiveness, and to explore the differential predictability of various frailty measurement models.
Eight databases were searched for prospective cohort studies that have adopted validated measure(s) of frailty and reported clinical, healthcare service utilization, or patient-reported outcomes in patients undergoing coronary artery or valvular surgeries/procedures.
Sixty-two articles were included (N = 16,679). Frailty significantly predicted mortality (short-term [≤ 30 days]: odds ratio [OR]: 2.33, 95% confidence interval [CI]: 1.28–4.26; midterm [6 months to 1 year]: OR: 3.93, 95%CI: 2.65–5.83; long-term [>1 year]: HR: 2.23, 95%CI: 1.60–3.11), postoperative complications (ORs: 2.54–3.57), discharge to care facilities (OR: 5.52, 95%CI: 3.84–7.94), hospital readmission (OR: 2.00, 95%CI: 1.15–3.50), and reduced health-related quality of life (HRQoL; standardized mean difference: −0.74, 95%CI: −1.30 to −0.18). Subgroup analyses showed that frailty exerted a greater impact on short-term mortality in patients undergoing open-heart surgeries than those receiving transcatheter procedures. Multidimensional and physical-aspect-focused frailty measurements performed equally in predicting mortality, but multidimensional measurements were more predictive of hospital readmission than physical-aspect-focused measurements.
Frailty was predictive of postoperative mortality, complications, increased healthcare service utilization, and reduced HRQoL. The impact of frailty on short-term mortality was more prominent in patients undergoing open-heart surgeries than those receiving transcatheter procedures. Multidimensional measures of frailty enhanced prognostic risk estimation, especially for hospital readmission.
Evaluating frailty may complement APACHE II in estimating mortality in elderly patients admitted to the ICU after digestive surgery
2022, Medicina Intensiva
Analizar si la fragilidad puede mejorar la predicción de mortalidad en los pacientes ingresados en UCI tras una cirugía digestiva.
Estudio prospectivo, observacional y con seguimiento a 6 meses de una cohorte de pacientes que ingresaron en UCI entre el 1 de junio de 2018 hasta el 1 de junio de 2019.
UCI quirúrgica de un hospital de tercer nivel.
Serie de pacientes sucesivos mayores de 70 años que ingresaron en UCI inmediatamente después de una intervención quirúrgica sobre el aparato digestivo. Fueron incluidos 92 pacientes y se excluyeron 2 por pérdida de seguimiento a los 6 meses.
Al ingreso en UCI se estimó gravedad y pronóstico mediante el APACHE II, y fragilidad mediante la Clinical Frailty Scale y el modified Frailty Index.
Mortalidad en UCI, intrahospitalaria y a los 6 meses.
El modelo que mejor predice mortalidad en UCI es el APACHE II, con un área bajo la curva ROC (ABC) de 0,89 y una buena calibración. El modelo que combina APACHE II y Clinical Frailty Scale es el que mejor predice mortalidad intrahospitalaria (ABC: 0,82), mejorando significativamente la predicción del APACHE II aislado (ABC: 0,78; Integrated Discrimination Index: 0,04). La fragilidad es un factor predictor de mortalidad a los 6 meses, siendo el modelo que combina la Clinical Frailty Scale y el modified Frailty Index el que ha demostrado mayor discriminación (ABC: 0,84).
La fragilidad puede complementar al APACHE II mejorando su predicción de mortalidad hospitalaria. Además, ofrece una buena predicción de la mortalidad a los 6 meses de la cirugía. Para la mortalidad en UCI, la fragilidad pierde su poder de predicción mientras que el APACHE II aislado muestra una excelente capacidad predictiva.
To analyze whether frailty can improve the prediction of mortality in patients admitted to the ICU after digestive surgery.
Prospective, observational, 6-month follow-up study of a cohort of patients admitted to the ICU between June 1, 2018, and June 1, 2019.
Surgical ICU of a third level hospital.
Series of successive patients older than 70 years who were admitted to the ICU immediately after a surgical intervention on the digestive system. 92 patients were included and 2 were excluded due to loss of follow-up at 6 months.
Upon admission to the ICU, severity and prognosis were assessed by APACHE II, and fragility by the Clinical Frailty Scale and the modified Frailty Index.
ICU, in-hospital and 6-month mortality.
The model that best predicts mortality in the ICU is the APACHE II, with an area under the ROC curve (AUC) of 0.89 and a good calibration. The model that combines APACHE II and Clinical Frailty Scale is the one that best predicts in-hospital mortality (AUC: 0.82), significantly improving the prediction of isolated APACHE II (AUC: 0.78; Integrated Discrimination Index: 0.04). Frailty is a predictor of mortality at 6 months, being the model that combines Clinical Frailty Scale and Frailty Index the one that has shown the greatest discrimination (AUC: 0.84).
Frailty can complement APACHE II by improving its prediction of hospital mortality. Furthermore, it offers a good prediction of mortality 6 months after surgery. For mortality in ICU, frailty loses its predictive power, whereas isolated APACHE II shows excellent predictive capacity.
Changes in frailty status after cardiac surgery. A prospective cohort study
2022, Archives of Gerontology and Geriatrics
Citation Excerpt :
This cohort of patients was first established to analyze the changes in the quality of life after cardiac surgery, according to the patient's preoperative frailty status. The results of this analysis have been recently published by our group (Miguelena-Hycka et al., 2019). In the present study, using the same cohort of patients, we analyzed the changes in the frailty status after cardiac surgery with respect to the preoperative levels.
The concept of frailty has become increasingly familiar in cardiac surgery. Since one of the characteristics of frailty is its reversible nature, efforts are being made to preoperatively decrease the level of frailty. However, the effect that the surgery itself may have in the postoperative frailty status remains still unknown.
A prospective cohort of 137 patients aged 70 or more undergoing major cardiac surgery were recruited at three hospitals in Spain. Frailty status was assessed preoperatively and six months after surgery using the Fried scale and the Clinical Frailty Scale (CFS). We analyzed the changes in these frailty scores and the transitions between frailty status after surgery.
Mean age of participants was 78.3 years. 47.7% were female. Prevalence of frailty was 27.5% with the Fried Scale and 11% with the CFS. Up to 50% of frail patients improved their frailty status after surgery. The distribution of frailty among the study groups at baseline and six months after surgery changed significantly, decreasing the overall burden of frailty after surgery: 27.5% vs 17.4% of frail patients with the Fried Scale and 50.5% vs 29.4% of vulnerable or frail patients with the CFS (p<0.01).
Frailty is a dynamic condition that can be significantly reduced after cardiac surgery, suggesting that cardiac pathology is an important contributor to the preoperative patient's frailty status.
Heart, home, and frailty: new risk scores and outcomes for cardiac surgery patients
2021, British Journal of Anaesthesia
Influence of frailty in the outcome of surgical patients over 70 years old with admission criteria in ICU
2021, Cirugia Espanola
El grado de fragilidad puede influir más que la edad o la gravedad en el pronóstico de pacientes mayores de 70 años intervenidos de cirugía del aparato digestivo que precisan control postoperatorio inmediato en UCI.
Estudio prospectivo y observacional de pacientes mayores de 70 años que ingresaron en UCI quirúrgica de un hospital de tercer nivel inmediatamente después de una intervención quirúrgica electiva o urgente sobre el aparato digestivo desde el 1 de junio de 2018 hasta el 1 de junio de 2019. Se registraron al ingreso las variables edad, fragilidad (Clinical Frailty Scale, CFS, y Modified Frailty Index, mFI), gravedad (APACHE II), tipo de cirugía y entidad quirúrgica. Se realizó un análisis bivariante para evaluar la influencia de la fragilidad y gravedad en la morbimortalidad hospitalaria y situación basal del paciente (en cuanto a dependencia) a 6 meses.
Fueron seleccionados 90 pacientes, de los que el 54,4% fueron reintervenidos; el 74,4% fueron dados de alta inicialmente en UCI, con un reingreso del 28,4% y con relación directa con la fragilidad (CFS y mFI: p < 0,01). La mortalidad global a los 6 meses fue 44,5%, con CFS (OR = 64,3; p < 0,05; IC 95%: 12,3-333,9) y APACHE II (OR = 1,17; p < 0,05; IC 95%: 1,04-1,32) fueron las covariables que mejor se relacionaron.
La estimación de la fragilidad mediante CSF y mFI tiene relación directa con la morbilidad quirúrgica y el reingreso de pacientes graves de edad avanzada ingresados en UCI. Además, CFS y mFI han resultado eficientes como predictores de mortalidad a los 6 meses.
Frailty degree can influence more than age or severity in the outcome of patients older than 70 years undergoing surgery of the digestive system that require immediate postoperative control in the ICU.
A prospective and observational study of patients over 70 years of age who were admitted to the surgical ICU of a third level hospital immediately after an elective or emergent surgical intervention on the digestive system from June 1, 2018 until June 1, 2019. The variables age, frailty Clinical Frailty Scale (CFS), and modified Frailty Index (mFI), severity (APACHE II), type of surgery, surgical pathology were recorded upon admission. A bivariate analysis was performed to assess the influence of frailty and severity on hospital morbidity and mortality and baseline situation of the patient (in terms of dependence) at 6 months.
A total of 90 patients were recruited, 54.4% of whom were reoperated; 74.4% were initially discharged from the ICU, with 28.4% of readmission and directly associated to frailty (CFS and mFI: P<0.01). The overall mortality at 6 months was 44.5% being CFS (OR = 64.3; P<0.05, 95% CI: 12.3-333.9) and APACHE II (OR = 1.17; P<0.05; 95% CI: 1.04-1.32) the covariates that best related.
The estimation of frailty by CSF and mFI is directly associated to the surgical morbidity and readmission of elderly and severe patients admitted to the ICU. In addition, CFS and mFI has been efficient as a predictive of mortality at 6 months.

View all citing articles on Scopus

View full text

Original articleAdult cardiacInfluence of Preoperative Frailty on Health-Related Quality of Life After Cardiac Surgery

Background

Methods

Results

Conclusions

Visual Abstract

Section snippets

Patient Population and Study Design

Results

Comment

J Am Coll Cardiol

J Thorac Cardiovasc Surg

Semin Thorac Cardiovasc Surg

J Am Coll Cardiol

Lancet

J Thorac Cardiovasc Surg

Value Health

J Chronic Dis

Semin Thorac Cardiovasc Surg

Ann Thorac Surg

J Nutr Health Aging

Frailty is a predictor of short-and mid-term mortality after elective cardiac surgery independently of age

Interact Cardiovasc Thorac Surg

Frail patients are at increased risk for mortality and prolonged institutional care after cardiac surgery

Circulation

Frailty in older adults: evidence for a phenotype

J Gerontol A Biol Sci Med Sci

Frailty and perioperative outcomes: a narrative review

Can J Anaesth J Can Anesth

The impact of frailty on patient-centered outcomes following aortic valve replacement

J Gerontol A Biol Sci Med Sci

A global clinical measure of fitness and frailty in elderly people

CMAJ

Original article
Adult cardiac
Influence of Preoperative Frailty on Health-Related Quality of Life After Cardiac Surgery