Pre-Frailty Increases the Risk of Adverse Events in Older Patients Undergoing Cardiovascular Surgery

Rodrigues, Miguel K.; Marques, Artur; Lobo, Denise M. L.; Umeda, Iracema I. K.; Oliveira, Mayron F.

doi:10.5935/abc.20170131

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Original Article • Arq. Bras. Cardiol. 109 (4) • Oct 2017 • https://doi.org/10.5935/abc.20170131 copy

Pre-Frailty Increases the Risk of Adverse Events in Older Patients Undergoing Cardiovascular Surgery

Authorship SCIMAGO INSTITUTIONS RANKINGS

Abstract

Background:

Frailty is identified as a major predictor of adverse outcomes in older surgical patients. However, the outcomes in pre-frail patients after cardiovascular surgery remain unknown.

Objective:

To investigate the main outcomes (length of stay, mechanical ventilation time, stroke and in-hospital death) in pre-frail patients in comparison with no-frail patients after cardiovascular surgery.

Methods:

221 patients over 65 years old, with established diagnosis of myocardial infarction or valve disease were enrolled. Patients were evaluated by Clinical Frailty Score (CFS) before surgery and allocated into 2 groups: no-frailty (CFS 1~3) vs. pre-frailty (CFS 4) and followed up for main outcomes. For all analysis, the statistical significance was set at 5% (p < 0.05).

Results:

No differences were found in anthropometric and demographic data between groups (p > 0.05). Pre-frail patients showed a longer mechanical ventilation time (193 ± 37 vs. 29 ± 7 hours; p<0.05) than no-frail patients; similar results were observed for length of stay at the intensive care unit (5 ± 1 vs. 3 ± 1 days; p < 0.05) and total time of hospitalization (12 ± 5 vs. 9 ± 3 days; p < 0.05). In addition, the pre-frail group had a higher number of adverse events (stroke 8.3% vs. 3.9%; in-hospital death 21.5% vs. 7.8%; p < 0.05) with an increased risk for development stroke (OR: 2.139, 95% CI: 0.622-7.351, p = 0.001; HR: 2.763, 95%CI: 1.206-6.331, p = 0.0001) and in-hospital death (OR: 1.809, 95% CI: 1.286-2.546, p = 0.001; HR: 1.830, 95% CI: 1.476-2.269, p = 0.0001). Moreover, higher number of pre-frail patients required homecare services than no-frail patients (46.5% vs. 0%; p < 0.05).

Conclusion:

Patients with pre-frailty showed longer mechanical ventilation time and hospital stay with an increased risk for cardiovascular events compared with no-frail patients.

Keywords:
Aging; Cardiovascular Surgery; Adverse Events; Fragility

	No-frailty	Pre-frailty	p value
	(n = 77)	(n = 144)	p value
Anthropometrics/Demographics
Male, n (%)	52 (67.5%)	93 (64.5%)	0.26
Age, years	70 ± 2	72 ± 4	0.42
Weight, kg	69.3 ± 9.8	73.4 ± 14.3	0.02
Height, m	1.64 ± 0.09	1.63 ± 0.10	0.76
BMI, kg/m²	25.4 ± 2.6	27.1 ± 3.9	0.001
LVEF, %	54 ± 12	55 ± 11	0.52
Euro Score	2 ± 0.5	6 ± 0.4	< 0.001
ASA	2 ± 0.3	3 ± 0.6	< 0.001
Main comorbidities
Hypertension, n (%)	58 (75.3%)	120 (83.3%)	0.01
Type II Diabetes, n (%)	27 (35%)	56 (38.8%)	0.12
Dyslipidemia, n (%)	33 (42.8%)	66 (45.8%)	0.38
Smoker, n (%)	14 (18.2%)	16 (11.1%)	0.09
Surgical data
Coronary artery bypass, n (%)	41 (53.2%)	83 (57.6%)	0.65
Valve replacement, n (%)	25 (32.4%)	42 (29.2%)	0.42
Coronary artery bypass + valve replacement, n (%)	11 (14.2%)	19 (13.2%)	0.71
Activated partial thromboplastin time, s	27 ± 6	25 ± 7	0.19
Cardiopulmonary bypass time, min	100 ± 40	90 ± 39	0.17
Cross-clamp time, min	73 ± 26	63 ± 31	0.12
Baseline hemodynamic and blood measurements
HR, bpm	97 ± 22	93 ± 19	0.21
MAP, mmHg	98 ± 11	101 ± 14	0.43
Hemoglobin, g/dL	10.7 ± 2.1	10.8 ± 1.7	0.68
Hematocrit, %	33.2 ± 6.0	33.9 ± 8.7	0.49
Platelets, mm³	143,126 ± 60,725	146,726 ± 53,742	0.64
Creatinine, mg/dL	1.16 ± 0.50	1.27 ± 0.54	0.54
hs-CRP, mg/L	8.8 ± 0.8	9.0 ± 0.8	0.86
PaO₂, mmHg	118 ± 5	117 ± 9	0.90
PaCO₂, mmHg	42 ± 11	39 ± 8	0.06
HCO₃^-, mmol/L	22 ± 2	21 ± 3	0.53
SpO₂, %	96 ± 4	97 ± 3	0.37

	No-frailty (n = 77)	Pre-frailty (n = 144)	p value
Length of stay
Intensive care unit, days	3 ± 1	5 ± 1	0.03
Total time hospitalization, days	9 ± 3	12 ± 5	< 0.001
Mechanical ventilation
Time in Mechanical ventilation, hours	29 ± 7	193 ± 37	0.001
Prolonged time in mechanical ventilation, n (%)	0	21 (14.5%)	0.001
Vasopressor
Noradrenaline, n (%)	26 (33.8%)	46 (31.9%)	0.87
Dobutamine, n (%)	8 (10.4%)	29 (20.1%)	0.03
Dopamine, n (%)	14 (18.2%)	15 (10.4%)	0.08
Nitroglicerine, n (%)	8 (10.4%)	20 (13.8%)	0.24
Adverse events
Infection, n (%)	4 (5.2%)	7 (4,8%)	0.69
Stroke, n (%)	3 (3.9%)	12 (8.3%)	0.02
In-hospital deaths, n (%)	6 (7.8%)	31 (21.5%)	0.001
Home care facility
Physiotherapy, n (%)	0	67 (46.5%)	< 0.001

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1 Very Fit - People who are robust, active, energetic and motivated. These people commonly exercise regularly. They are among the fittest for their age.	6 Moderately Frail - People need help with all outside activities and with keeping house. Inside, they often have problems with stairs and need help with bathing and might need minimal assistance (cuing, standby) with dressing.
2 Well - People who have no active disease symptoms but are less fit than category 1. Often, they exercise or are very active occasionally, e.g. seasonally.	7 Severely Frail - Completely dependent for personal care, from whatever cause (physical or cognitive). Even so, they seem stable and not at high risk of dying (within ~ 6 months).
3 Managing Well - People whose medical problems are well controlled, but are not regularly active beyond routine walking.	8 Very Severely Frail - Completely dependent, approaching the end of life. Typically, they could not recover even from a minor illness.
4 Vulnerable - While not dependent on others for daily help, often symptoms limit activities. A common complaint is being “slowed up”, and/or being tired during the day.	9 Terminally iII - Approaching the end of life. This category applies to people with a life expectancy <6 months, who are not otherwise evidently frail.
5 Mildly Frail - These people often have more evident slowing, and need help in high order IADLs (finances, transportation, heavy housework, medications). Typically, mild frailty progressively impairs shopping and walking outside alone, meal preparation and housework.

	OR	95%CI	p value
Stroke	2.139	0.622 - 7.351	0.001
In-hospital deaths	2.763	1.206 - 6.331	0.0001
	HR	95%CI	p value
Stroke	1.809	1.286 - 2.546	0.001
In-hospital deaths	1.830	1.476 - 2.269	0.0001