THE ESSENTIAL FRAILTY TOOLSET IN OLDER ADULTS UNDERGOING CABG

Abstract

Frailty is prevalent and associated with adverse outcomes in older adults undergoing cardiac procedures, however, there remains uncertainty about the ideal tool to measure it. The Essential Frailty Toolset (EFT) was previously developed in patients undergoing aortic valve replacement procedures and found to be superior to other tools. The EFT has yet to be evaluated in patients undergoing coronary artery bypass grafting (CABG) surgery. Data was collected from a prospective cohort of patients ≥60 years of age undergoing CABG without concomitant valve replacement between 2011-2018 at two university hospitals (Jewish General Hospital, Royal Victoria Hospital; Montreal, QC). The EFT was assessed pre-operatively and scored 0 to 5 points as a function of five chair rises (1 point if >15 seconds, 2 points if unable), mini-mental status examination (1 point if <24), serum albumin (1 point if <35), and hemoglobin (1 point if <130 in men or <120 in women). The primary outcome was 1-year all-cause death or worsening disability defined as institutionalization or ≥2 new disabilities in basic or instrumental activities of daily living. The cohort consisted of 520 patients with a mean age of 71.4 ± 6.4 years. The mean EFT score was 1.3 ± 1.1 points, with 137 (26%) being non-frail with an EFT of 0 points, 306 (59%) being pre-frail with an EFT of 1-2 points, and 77 (15%) being frail with an EFT of 3-5 points. The incidence of 1-year death or worsening disability was 6% in non-frail patients, 12% in pre-frail patients, and 29% in frail patients. After adjusting for the STS predicted risk of mortality in a Cox proportional hazards model, each incremental EFT point was associated with a hazard ratio of 1.41 (95% CI 1.10 to 1.82) for the primary outcome. After adjusting for individual covariates (age, sex, ejection fraction, redo, urgent surgery), each incremental EFT point was similarly associated with a hazard ratio of 1.44 (95% CI 1.14 to 1.83) such that frail patients had a 2.6 fold increase in the primary outcome. The EFT is a valid, rapid, and highly prognostic tool to assess frailty in older adults undergoing CABG. Furthermore, the subdomains of the EFT may be actionable through targeted interventions such as cardiac rehabilitation, nutritional optimization, and iron replacement.