Division of Vascular Surgery, Department of Surgery, University of Washington, Seattle, Wash.
Division of Vascular Surgery, Department of Surgery, University of Utah School of Medicine, Salt Lake City, Utah.
J Vasc Surg. 2019 Sep;70(3):892-900. doi: 10.1016/j.jvs.2018.11.025. Epub 2019 Mar 6.
Frailty and sarcopenia are related but independent conditions commonly diagnosed in older patients that can be used to assess their ability to tolerate the stress of major vascular surgery. For surgical decision-making, however, it is important to know the prognostic implications associated with each of these conditions. The study was designed to assess the association of frailty and sarcopenia phenotypes with long-term survival of patients undergoing surgical and nonsurgical management of vascular disease.
We retrospectively reviewed all patients presenting to the vascular surgery clinic at an academic hospital between December 2015 and August 2017 who underwent prospective frailty assessment with the Clinical Frailty Scale and who had abdominal computed tomography (CT) scans performed within the preceding 12 months. A single axial CT image at the caudal end of the third lumbar vertebra was assessed to measure cross-sectional areas of skeletal muscle. Sarcopenia was defined by established criteria specific for male and female patients. After patients were stratified by frailty and sarcopenia diagnoses along with comorbidities, the association with all-cause mortality was analyzed by Kaplan-Meier curves and Cox regression models.
A total of 415 patients underwent both frailty and sarcopenia assessment, of whom 112 (27%) met sarcopenia criteria alone, 48 (12%) met only frailty criteria, and 56 (13%) met criteria for both phenotypes. There were 199 (48%) controls who met neither criterion. Vascular operations were performed in 167 (40%) patients after frailty and sarcopenia assessment, whereas 248 (60%) patients were managed nonoperatively with median (interquartile range) follow-up after CT imaging of 1.5 (1.1-2.2) years. Patients diagnosed with either phenotype were older (mean, 65 years vs 59 years; P < .001) and more likely to be male (69% vs 54%; P < .001) compared with patients without sarcopenia or frailty. Long-term survival was significantly decreased for patients diagnosed with either frailty alone or frailty and sarcopenia who underwent surgical or nonsurgical management (log-rank, P < .001 for both comparisons). In multivariate regression models, however, frailty was the only independent variable (hazard ratio, 7.7; 95% confidence interval, 3.2-18.7; P < .001) that predicted mortality.
Frailty and sarcopenia overlap to varying degrees in patients presenting to vascular surgery clinics and can be used alone or in combination to predict long-term survival of older patients. However, our data indicate that it was only the diagnosis of frailty that was an independent predictor of mortality and had the strongest prognostic significance in patients undergoing both surgical and nonoperative management.
衰弱和肌少症是常见于老年患者的两种相关但独立的疾病，可以用于评估他们对大血管手术应激的耐受能力。然而，对于手术决策，了解这两种情况各自的预后意义非常重要。本研究旨在评估衰弱和肌少症表型与接受手术和非手术治疗的血管疾病患者的长期生存之间的关联。
我们回顾性分析了 2015 年 12 月至 2017 年 8 月期间在学术医院血管外科诊所就诊的所有患者，这些患者接受了临床虚弱量表的前瞻性虚弱评估，并在之前的 12 个月内进行了腹部计算机断层扫描（CT）检查。在第三腰椎尾部的单个轴向 CT 图像上评估骨骼肌的横截面积。根据特定于男性和女性患者的既定标准定义肌少症。根据虚弱和肌少症诊断以及合并症对患者进行分层后，通过 Kaplan-Meier 曲线和 Cox 回归模型分析与全因死亡率的关联。
共有 415 名患者同时接受了虚弱和肌少症评估，其中 112 名（27%）符合肌少症标准，48 名（12%）仅符合虚弱标准，56 名（13%）符合两种表型标准。有 199 名（48%）患者既不符合也不符合标准。在进行虚弱和肌少症评估后，167 名（40%）患者接受了血管手术，而 248 名（60%）患者接受了非手术治疗，CT 成像后中位（四分位距）随访时间为 1.5（1.1-2.2）年。与无肌少症或虚弱的患者相比，被诊断为任一种表型的患者年龄更大（平均 65 岁比 59 岁；P<0.001），且更可能为男性（69%比 54%；P<0.001）。接受手术或非手术治疗的单独患有虚弱或同时患有虚弱和肌少症的患者的长期生存率显著降低（对数秩检验，两种比较的 P<0.001）。然而，在多变量回归模型中，只有虚弱是唯一的独立变量（危险比，7.7；95%置信区间，3.2-18.7；P<0.001），可预测死亡率。
衰弱和肌少症在血管外科诊所就诊的患者中存在不同程度的重叠，可以单独或联合使用来预测老年患者的长期生存。然而，我们的数据表明，只有衰弱的诊断是死亡率的独立预测因素，并且在接受手术和非手术治疗的患者中具有最强的预后意义。
