Perioperative Cardiac Risk Assessment for the Frail Older Adult

Abstract

The Canadian Cardiovascular Society guidelines on perioperative cardiac risk assessment and management for patients who undergo noncardiac surgery1Duceppe E. Parlow J. MacDonald P. et al.Canadian Cardiovascular Society guidelines on perioperative cardiac risk assessment and management for patients who undergo noncardiac surgery.Can J Cardiol. 2017; 33: 17-32Abstract Full Text Full Text PDF PubMed Scopus (378) Google Scholar do not reflect the needs of the frail older adult population compared with their younger counterparts. The leading cause of death and major disability in adults aged 75 years and older is cardiovascular disease.2Rich M.W. Chyun D.A. Skolnick A.H. et al.Knowledge gaps in cardiovascular care of older adults: a scientific statement from the American Heart Association, American College of Cardiology, and American Geriatrics Society: executive summary.J Am Geriatr Soc. 2016; 64: 2185-2192Crossref PubMed Scopus (47) Google Scholar We acknowledge that guidelines have challenges in providing high-quality evidence-based recommendations that specifically apply to frail older adults.2Rich M.W. Chyun D.A. Skolnick A.H. et al.Knowledge gaps in cardiovascular care of older adults: a scientific statement from the American Heart Association, American College of Cardiology, and American Geriatrics Society: executive summary.J Am Geriatr Soc. 2016; 64: 2185-2192Crossref PubMed Scopus (47) Google Scholar However, older adults have been considerably under-represented in most cardiovascular trials.2Rich M.W. Chyun D.A. Skolnick A.H. et al.Knowledge gaps in cardiovascular care of older adults: a scientific statement from the American Heart Association, American College of Cardiology, and American Geriatrics Society: executive summary.J Am Geriatr Soc. 2016; 64: 2185-2192Crossref PubMed Scopus (47) Google Scholar In particular, those with multimorbidity, frailty, significant physical disabilities, cognitive impairment, and patients residing in nursing homes and assisted living facilities have been excluded.2Rich M.W. Chyun D.A. Skolnick A.H. et al.Knowledge gaps in cardiovascular care of older adults: a scientific statement from the American Heart Association, American College of Cardiology, and American Geriatrics Society: executive summary.J Am Geriatr Soc. 2016; 64: 2185-2192Crossref PubMed Scopus (47) Google Scholar For these reasons, it cannot be assumed that outcomes from trials with younger populations can be applied to frail older adults.2Rich M.W. Chyun D.A. Skolnick A.H. et al.Knowledge gaps in cardiovascular care of older adults: a scientific statement from the American Heart Association, American College of Cardiology, and American Geriatrics Society: executive summary.J Am Geriatr Soc. 2016; 64: 2185-2192Crossref PubMed Scopus (47) Google Scholar “Older age is an independent predictor of perioperative complications and death after cardiac and noncardiac surgery.”2Rich M.W. Chyun D.A. Skolnick A.H. et al.Knowledge gaps in cardiovascular care of older adults: a scientific statement from the American Heart Association, American College of Cardiology, and American Geriatrics Society: executive summary.J Am Geriatr Soc. 2016; 64: 2185-2192Crossref PubMed Scopus (47) Google Scholar Frailty, defined as “an age-related cumulative decline in multiple physiologic systems,” has been proposed as a better predictor of morbidity and mortality than chronological age.3Lin H.S. Watts J.N. Peel N.M. Hubbard R.E. Frailty and post-operative outcomes in older surgical patients: a systematic review.BMC Geriatr. 2016; 16: 157Crossref PubMed Scopus (472) Google Scholar There is strong evidence that frailty in older surgical patients predicts postoperative mortality, complications, and prolonged length of hospital stay.3Lin H.S. Watts J.N. Peel N.M. Hubbard R.E. Frailty and post-operative outcomes in older surgical patients: a systematic review.BMC Geriatr. 2016; 16: 157Crossref PubMed Scopus (472) Google Scholar We propose the perioperative evaluation of older adults involve collaboration with those who have expertise in the care of older frail adults. In a recent systematic review it was reported that comprehensive geriatric assessment (CGA) reduces mortality in emergency surgical patients.4Eamer G. Saravana-Bawan B. van der Westhuizen B. et al.Economic evaluations of comprehensive geriatric assessment in surgical patients: a systematic review.J Surg Res. 2017; 218: 9-17Abstract Full Text Full Text PDF PubMed Scopus (25) Google Scholar CGA is a “multidimensional assessment designed to define an elderly individual's medical, psychosocial, and functional capabilities and allow for restoration of their premorbid function.”4Eamer G. Saravana-Bawan B. van der Westhuizen B. et al.Economic evaluations of comprehensive geriatric assessment in surgical patients: a systematic review.J Surg Res. 2017; 218: 9-17Abstract Full Text Full Text PDF PubMed Scopus (25) Google Scholar Moreover, CGA improves return of function and has been reported to be the most cost-effective care model for orthogeriatric patients.4Eamer G. Saravana-Bawan B. van der Westhuizen B. et al.Economic evaluations of comprehensive geriatric assessment in surgical patients: a systematic review.J Surg Res. 2017; 218: 9-17Abstract Full Text Full Text PDF PubMed Scopus (25) Google Scholar To further optimize perioperative care for geriatric patients, we must encourage close collaboration between cardiology and geriatric medicine in the creation of a Canadian best practices guideline. Let this serve as a call to action for the authors of the Canadian Cardiovascular Society guidelines on perioperative cardiac risk assessment and management for patients who undergo noncardiac surgery1Duceppe E. Parlow J. MacDonald P. et al.Canadian Cardiovascular Society guidelines on perioperative cardiac risk assessment and management for patients who undergo noncardiac surgery.Can J Cardiol. 2017; 33: 17-32Abstract Full Text Full Text PDF PubMed Scopus (378) Google Scholar to consider the frail older adult's unique needs to improve perioperative outcomes. The authors have no conflicts of interest to disclose. Canadian Cardiovascular Society Guidelines on Perioperative Cardiac Risk Assessment and Management for Patients Who Undergo Noncardiac SurgeryCanadian Journal of CardiologyVol. 33Issue 1PreviewThe Canadian Cardiovascular Society Guidelines Committee and key Canadian opinion leaders believed there was a need for up to date guidelines that used the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) system of evidence assessment for patients who undergo noncardiac surgery. Strong recommendations included: 1) measuring brain natriuretic peptide (BNP) or N-terminal fragment of proBNP (NT-proBNP) before surgery to enhance perioperative cardiac risk estimation in patients who are 65 years of age or older, are 45-64 years of age with significant cardiovascular disease, or have a Revised Cardiac Risk Index score ≥ 1; 2) against performing preoperative resting echocardiography, coronary computed tomography angiography, exercise or cardiopulmonary exercise testing, or pharmacological stress echocardiography or radionuclide imaging to enhance perioperative cardiac risk estimation; 3) against the initiation or continuation of acetylsalicylic acid for the prevention of perioperative cardiac events, except in patients with a recent coronary artery stent or who will undergo carotid endarterectomy; 4) against α2 agonist or β-blocker initiation within 24 hours before surgery; 5) withholding angiotensin-converting enzyme inhibitor and angiotensin II receptor blocker starting 24 hours before surgery; 6) facilitating smoking cessation before surgery; 7) measuring daily troponin for 48 to 72 hours after surgery in patients with an elevated NT-proBNP/BNP measurement before surgery or if there is no NT-proBNP/BNP measurement before surgery, in those who have a Revised Cardiac Risk Index score ≥1, age 45-64 years with significant cardiovascular disease, or age 65 years or older; and 8) initiating of long-term acetylsalicylic acid and statin therapy in patients who suffer myocardial injury/infarction after surgery. Full-Text PDF Frailty, the Elderly, and the Guidelines on Perioperative Cardiac Risk Assessment and Management in Noncardiac SurgeryCanadian Journal of CardiologyVol. 34Issue 3PreviewWhitney et al.1 correctly point out the growing evidence that frailty is a predictor of a variety of complications after surgery and that high-quality evidence for the optimal management of this population has been lacking in the cardiovascular literature. The Canadian Cardiovascular Society (CCS) Guidelines on Perioperative Cardiac Risk Assessment and Management for Patients Who Undergo Noncardiac Surgery is a focused document examining preoperative risk assessment, perioperative risk modification, postoperative monitoring for events, and management of cardiac events (the authors of this article participated on the primary panel of the CCS Guidelines on Perioperative Risk Assessment and Management for Patients Who Undergo Noncardiac Surgery and authored the guidelines document). Full-Text PDF