Cardiac Surgery In Older Patients Research Articles

Atrial Fibrillation at Discharge in Older Cardiac Surgery Patients: A Prospective Study of Prevalence and Associated Medication Utilization

Although postoperative atrial fibrillation (AF) is prevalent after cardiac surgery, the corresponding medication burden associated with this postoperative arrhythmia is unknown. We conducted a prospective study of 204 patients aged 60 or older (median age 73) undergoing cardiac surgery at two academic medical centers. We defined "AF at discharge" as AF that developed after surgery and was present on the day of discharge. We evaluated the prevalence of anticoagulant and antiarrhythmic use at discharge, and out to 1 year post-discharge. We investigated the association between age and prescription of both classes of medications at discharge. Ninety-one (45%) patients developed new postoperative AF, which persisted at discharge in 28 (14%) patients. Thirty-four percent of patients with postoperative AF were discharged on warfarin, 62% were discharged on antiarrhythmic medication, and 25% were discharged on both. Eighty-two percent of those discharged on both were older than 72 years of age. Patients with AF present at discharge were more likely to be discharged on anticoagulant agents than patients whose AF resolved prior to discharge (54% versus 26%, p=0.01), and more likely to be discharged on antiarrhythmic agents than patients whose AF resolved prior to discharge, though not significantly so (73% versus 57%, p=0.2). At 12 months, the proportion of patients on antiarrhythmic and anticoagulant medications had still not returned to preoperative rates. AF persists at hospital discharge in nearly one-third of affected patients. Cardiac surgery results in the initiation of anticoagulant and antiarrhythmic medications in many older patients annually, often concurrently. Our findings underscore the need for additional studies on the natural history of this arrhythmia and clinical trials investigating different management strategies after discharge. Such research will help to inform development of guidelines addressing duration of use for these medications, to aid physicians in these complicated post-discharge management decisions.

Predicting prolonged intensive care unit stays in older cardiac surgery patients: a validation study

In cardiac surgery prediction models identifying patients at risk of prolonged stay at the Intensive Care Unit (ICU) are used to optimize treatment and use of ICU resources. A recent systematic validation study of 14 of these models identified three models with a good predictive performance across patients of all ages. It is however unclear how these models perform in older patients, who nowadays form a considerable part of this patient population. The current study specifically validates the performance of these three models in older cardiac surgery patients and quantifies how their performance changes with increasing age of patients. The Parsonnet model, the EuroSCORE, and a model by Huijskes and colleagues were validated using prospectively collected data of 11,395 cardiac surgery patients. Performance of the models was described by discrimination (area under the ROC curve, AUC) and calibration. For the Parsonnet model, the EuroSCORE and the Huijskes model discrimination clearly decreased with increasing age (AUCs of 0.76, 0.71 and 0.72 for ages 70-75 and 0.72, 0.70 and 0.72, respectively, for ages 75-80 and 0.68, 0.64 and 0.69, respectively, above 80 years). The models showed poor calibration in patients aged >70 (p values for fit of the models <0.006). To optimize treatment and ICU resources, risk prediction for prolonged ICU stay after cardiac surgery using the existing models should be done with great care for older patients.

Development of a unidimensional composite measure of neuropsychological functioning in older cardiac surgery patients with good measurement precision

The objective of this analysis was to develop a measure of neuropsychological performance for cardiac surgery and to assess its psychometric properties. Older patients (n = 210) underwent a neuropsychological battery using nine assessments. The number of factors was identified with variable reduction methods. Factor analysis methods based on item response theory were used to evaluate the measure. Modified parallel analysis supported a single factor, and the battery formed an internally consistent set (coefficient alpha = .82). The developed measure provided a reliable, continuous measure (reliability > .90) across a broad range of performance (–1.5 SDs to +1.0 SDs) with minimal ceiling and floor effects.

Is Preoperative Anxiety and Depression Associated with Onset of Delirium After Cardiac Surgery in Older Patients? A Prospective Cohort Study

To investigate the prevalence of preoperative anxiety and depressive symptoms and their relationship with the occurrence of postcardiac delirium and to describe the evolution of these symptoms from preoperative admission until discharge. Descriptive, prospective, longitudinal study. The intensive care unit and two cardiac surgery units in a university hospital setting. One hundred four patients (median age 71; 78.8% men) admitted for elective cardiac surgery. Anxiety measured preoperatively using the State-Trait Anxiety Inventory (STAI) and the Hospital Anxiety and Depression Scale (HADS); depression using the HADS; cognitive functioning using the Mini-Mental State Examination (MMSE); delirium using the Confusion Assessment Method (CAM), the CAM for the Intensive Care Unit (CAMICU), and the Delirium Index (DI); and activities of daily living using the Katz index of activities of daily living (Katz ADL scale). MMSE, CAM/CAM-ICU, and DI were obtained on postoperative Days 1, 3, and 7. On Day 7 and at discharge, the STAI, HADS, and Katz ADL scale were repeated. Postoperative delirium occurred in 26%; 55.8% reported preoperative state anxiety, 25.2% generalized anxiety, and 15.5% depressive symptoms, but no association was found with delirium occurrence. Based on multivariable analysis, prolonged intubation time (odds ratio (OR)51.10, CI: 1.05-1.15, P5.001) and a low intraoperative lowest body temperature (OR50.86, CI: 0.74-0.99, P5.03) were independent predictors of delirium onset. At discharge, 35.7% and 12.2% of patients reported state anxiety and generalized, and 15.3% reported depressive symptoms. Despite the high prevalence of preoperative anxiety and depressive symptoms in older patients with cardiac surgery, no association was found with postoperative delirium.

Changing colours

<h3>Introduction</h3> Postoperative delirium is common in older cardiac surgery patients and associated with negative short-term and long-term outcomes. The alpha-2-adrenergic receptor agonist dexmedetomidine shows promise as prophylaxis and treatment for...

Health‐Related Quality of Life Predicts Mortality in Older but Not Younger Patients Following Cardiac Surgery

The investigators assessed preoperative health-related quality of life as a predictor of 6-month mortality after cardiac surgery in older (65 years of age and older) vs. younger patients. Multivariable regression, stratified by age groups, was used to compare the association between preoperative Physical Component Summary and Mental Component Summary scores from the Short Form-36 health status survey and mortality. In multivariable analyses of older patients, lower preoperative Physical Component Summary (odds ratio, 1.54; 95% confidence interval, 1.19-2.00; p=0.01) and Mental Component Summary (odds ratio, 1.26; 95% confidence interval, 1.06-1.49; p=0.03) scores were independently associated with mortality. In contrast, neither Physical Component Summary (p=0.82) nor Mental Component Summary (p=0.79) scores were associated with mortality in the younger subgroup. This study demonstrated that preoperative health status is an independent predictor of mortality following cardiac surgery in older but not younger patients. Preoperative patient self-report of health status may be particularly useful in refining risk stratification and informing decision-making before and following cardiac surgery in older patients.

Cirugía cardíaca en el anciano

The morbimortality of elderly patients, (age 70 years or older), who underwent surgery for valvular and coronary artery disease in the last 17 years was analyzed. A total of 1,305 patients (654 valvular, 531 coronary and 120 combined) operated from January 1985 to December 2000 were retrospectively studied. Mean age was 73.7 years. We analyzed the progression of the pathology, comorbidity, and results. A second retrospective analysis was made of patients who underwent surgery in the last three years (436 patients) to determine the relation between preoperative comorbidity and postoperative evolution. The mean hospital mortality was 16% (18% valvular, 11% coronary artery, and 23% combined). In the last three years this mortality was reduced to 11% (15.17, 6.26, and 16.18%, respectively) despite an increase in comorbidity. Comorbidity and complications increased with age (p < 0.05). Mean hospital stay was 15.5 days and the stay in intensive/semi-intensive care was 5 days. Independent risk factors of postoperative complications were creatinine levels > 2 mg/dl, combined surgery, and prior surgery. Predictors of death were prior surgery, valvular surgery, and combined surgery, with a clear tendency in the case of obesity. The presence of any complication in the postoperative period (renal or respiratory failure, infections, or myocardial infarction) was an independent predictor of mortality. Off-pump coronary surgery reduced mortality. In recent years, the mortality of patients operated without extracorporeal circulation has decreased from 5.71% to 4% for those who underwent extracorporeal circulation. Nowadays, cardiac surgery in older patients accounts for more than 30% of our surgical activity. Mortality is being controlled although comorbidity is increasing. The difference with respect to younger people is due to comorbidity (creatinine > 2 mg/dl, combined surgery, and previous surgery) and the higher probability of complications (infections, renal, and respiratory complications), which worsens prognosis. We believe that off-pump coronary surgery helps to improve results.

“We don't do that here”: Reflections on the Siena experience with dissecting aneurysms of the thoracic aorta in octogenarians

In this issue of the Journal, Neri and his colleagues provide empirical evidence to support sparing octogenarians, their families, and their caregivers from the tragic experience the authors encountered with operative treatment of type A dissections of the thoracic aorta. Of 24 consecutive surgically treated patients in this age group, 8 died intraoperatively, 12 more died without leaving the hospital, and none of the 4 who were discharged lived beyond 6 months. No survivor returned to “a normal, functioning, integrated” life, the criterion used by the Massachusetts courts to justify a physician’s decision to withhold resuscitative measures. 1 Their report is courageous, because poor outcomes are rarely published; authors and journals usually compete instead to proclaim favorable results of cardiac surgery in older patients. The Sienna group recommends a professional guideline that excludes octogenarians from surgical treatment of type A aortic aneurysms. In this commentary, I will argue that creating a local institutional policy, with public as well as professional participation, is a more prudent approach. When patients, families, and surgeons are required to make decisions about the initiation or withdrawal of heroic life-sustaining treatments, a clear and reasonable institutional policy can be helpful to all. Judicious policies are now widely used to enable the harvest of organs for transplantation and for protection of the irretrievably ill from intubation and resuscitation by cardiac arrest teams. Guidelines, as suggested by Neri and associates, can be helpful in establishing the standard of care. They are

Frequency and Correlates of Adjustment Disorder Related to Cardiac Surgery in Older Patients

The diagnosis of adjustment disorder is a dilemma in older medically ill patients. The authors conducted a prospective study of older cardiac surgery patients. Semistructured interview techniques were used to distinguish emotional impairment from physical impairment to diagnose an adjustment disorder. Among 71 patients interviewed at three points in time, 50.7% had an adjustment disorder. At 6 months after surgery, 30.6% were still showing evidence of emotional functional impairment. Continued impairment was related to initial severity of depressive and anxiety symptoms. Implications and suggestions for future research are discussed.

Social Support and Depression After Cardiac Surgery in Elderly Patients

Two methods of measuring social support components were compared for their ability to predict depression 6 months after cardiac surgery in older patients (N = 155). Multiple regression models were used to compare summary support measures with subtype measures. A personality inventory was also included to rule out the possibility that significant findings about relationships of depression and social support were due primarily to personality dimensions. In the summary model, only the number of network members seen regularly was associated with less depression. In the subtype model, the number of relatives seen regularly and perceived adequacy of support from friends were associated with less depression, whereas receipt of tangible support was associated with more. When examined together with personality dimensions, both the summary components and subtypes of components of social support were better predictors of depressive symptomatology than the personality dimensions. The results helped confirm the importance of social support factors to the occurrence of depression in elderly patients and suggested that measures of social support subtypes were more informative than summary measures of social support.

Coronary artery surgery in octogenarians

Coronary surgery is being performed increasingly in older patients who may have more extensive disease as well as other factors that may lead to more frequent complications and death. 1–3 Several studies have shown that the rate of complications and mortality in elderly patients are higher than in younger ones. 4–7 Advanced age has also been shown to correlate with late mortality after cardiac surgery. 8 Because of these data, there has been uncertainty as to use of cardiac surgery in older patients, especially in those aged ≥80 years. This report presents results of coronary artery bypass grafting both in hospital and at follow-up in patients aged ≥80.