Rady Mohamed Y, Johnson Daniel J
Department of Critical Care Medicine, Mayo Clinic Hospital, Mayo Clinic Scottsdale, Phoenix, Ariz, USA.
Am Heart J. 2004 Feb;147(2):347-53. doi: 10.1016/j.ahj.2003.05.001.
Cardiac surgery is frequently performed to palliate cardiovascular symptoms in patients who are octogenarians, without controlled clinical trials to support its benefits. We hypothesized that death or discharge to a nursing care facility after cardiac surgery is similar in patients who are octogenarians and younger patients.
We conducted an inception cohort study in a tertiary care teaching hospital in patients who had undergone coronary grafting, valve surgery, or both over 36 months before. We collected data on preoperative disease, operation characteristics, postoperative complications, and outcome at hospital discharge.
Of 783 patients who had cardiac surgery, 96 were octogenarians. Female sex, pulmonary hypertension, previous malignancy, cerebral vascular disease, valvular heart disease, and congestive heart failure were more frequent in patients who were octogenarians than in younger patients. Operative characteristics were similar in both age groups, except there were more frequent valve or combined with coronary grafts surgery and surgical re-exploration in octogenarians. The rate of postoperative complications including cardiovascular, neurological, renal, and nosocomial infections were higher in patients who were octogenarians than younger patients. Death or discharge to a nursing care facility was more frequent in patients who were octogenarians than younger patients (53% vs 14%, P <.002). Age > or =80 years, female sex, congestive heart failure, and surgical re-exploration were independent predictors for death or discharge to a nursing care facility after cardiac surgery.
The rate of death or discharge to nursing care facility after cardiac surgery was high among patients who were octogenarians. Current operative outcome end points do not reflect such important differences between patients who are octogenarians and younger patients. Informed discussion of treatment options, potential for discharge to a nursing care facility, and quality of life expectations should precede a decision to undergo cardiac surgery in patients who are octogenarians. Randomized clinical trials of medical versus surgical palliation of cardiovascular symptoms in patients who are octogenarians are needed to justify cost-effectiveness and guide better use of relatively scarce Medicare resources.
心脏手术常用于缓解八旬老人的心血管症状，但缺乏对照临床试验来支持其益处。我们假设八旬老人心脏手术后死亡或出院后入住护理机构的情况与年轻患者相似。
我们在一家三级护理教学医院进行了一项队列研究，研究对象为36个月前接受过冠状动脉搭桥术、瓣膜手术或两者皆有的患者。我们收集了术前疾病、手术特征、术后并发症及出院结局的数据。
在783例接受心脏手术的患者中，96例为八旬老人。八旬老人中女性、肺动脉高压、既往恶性肿瘤、脑血管疾病、瓣膜性心脏病和充血性心力衰竭比年轻患者更为常见。两个年龄组的手术特征相似，但八旬老人中瓣膜手术或联合冠状动脉搭桥术以及再次手术探查更为频繁。八旬老人术后包括心血管、神经、肾脏和医院感染在内的并发症发生率高于年轻患者。八旬老人死亡或出院后入住护理机构的情况比年轻患者更为常见（53%对14%，P<.002）。年龄≥80岁、女性、充血性心力衰竭和再次手术探查是心脏手术后死亡或出院后入住护理机构的独立预测因素。
八旬老人心脏手术后死亡或出院后入住护理机构的比例较高。目前的手术结局终点并未反映出八旬老人与年轻患者之间的这种重要差异。在决定为八旬老人进行心脏手术之前，应就治疗方案、出院后入住护理机构的可能性以及生活质量期望进行充分的讨论。需要对八旬老人心血管症状的药物治疗与手术治疗进行随机临床试验，以证明成本效益并指导更好地利用相对稀缺的医疗保险资源。
