Division of Cardiac Anesthesiology, University of Ottawa Heart Institute, Ottawa, Ontario, Canada.
Cardiovascular Research Program, Institute for Clinical Evaluative Sciences, Toronto, Ontario, Canada.
JAMA Netw Open. 2022 Sep 1;5(9):e2230959. doi: 10.1001/jamanetworkopen.2022.30959.
Little is known about the performance of available frailty instruments in estimating patient-relevant outcomes after cardiac surgery.
To examine how well the Johns Hopkins Adjusted Clinical Groups (ACG) frailty indicator, the Hospital Frailty Risk Score (HFRS), and the Preoperative Frailty Index (PFI) estimate long-term patient-centered outcomes after cardiac surgery.
DESIGN, SETTING, AND PARTICIPANTS: This retrospective cohort study was conducted in Ontario, Canada, among residents 18 years and older who underwent coronary artery bypass grafting or aortic, mitral or tricuspid valve, or thoracic aorta surgery between October 2008 and March 2017. Long-term care residents, those with discordant surgical encounters, and those receiving dialysis or dependent on a ventilator within 90 days were excluded. Statistical analysis was conducted from July 2021 to January 2022.
The primary outcome was patient-defined adverse cardiovascular and noncardiovascular events (PACE), defined as the composite of severe stroke, heart failure, long-term care admission, new-onset dialysis, and ventilator dependence. Secondary outcomes included mortality and individual PACE events. The association between frailty and PACE was examined using cause-specific hazard models with death as a competing risk, and the association between frailty and death was examined using Cox models. Areas under the receiver operating characteristic curve (AUROC) were determined over 10 years of follow-up for each frailty instrument.
Of 88 456 patients (22 924 [25.9%] female; mean [SD] age, 66.3 [11.1] years), 14 935 (16.9%) were frail according to ACG criteria, 63 095 (71.3%) according to HFRS, and 76 754 (86.8%) according to PFI. Patients with frailty were more likely to be older, female, and rural residents; to have lower income and multimorbidity; and to undergo urgent surgery. Patients meeting ACG criteria (hazard ratio [HR], 1.66; 95% CI, 1.60-1.71) and those with higher HFRS scores (HR per 1.0-point increment, 1.10; 95% CI, 1.09-1.10) and PFI scores (HR per 0.1-point increment, 1.75; 95% CI, 1.73-1.78) had higher rates of PACE. Similar magnitudes of association were observed for each frailty instrument with death and individual PACE components. The HFRS had the highest AUROC for estimating PACE during the first 2 years and death during the first 4 years, after which the PFI had the highest AUROC.
These findings could help to tailor the use of frailty instruments by outcome and follow-up duration, thus optimizing preoperative risk stratification, patient-centered decision-making, candidate selection for prehabilitation, and personalized monitoring and health resource planning in patients undergoing cardiac surgery.
对于可用的衰弱指标在评估心脏手术后与患者相关的结局方面的表现，人们知之甚少。
研究约翰霍普金斯调整临床分组（ACG）衰弱指标、医院衰弱风险评分（HFRS）和术前衰弱指数（PFI）在多大程度上可以预测心脏手术后的长期患者为中心结局。
设计、地点和参与者：这是一项在加拿大安大略省进行的回顾性队列研究，研究对象为 2008 年 10 月至 2017 年 3 月期间接受冠状动脉旁路移植术或主动脉、二尖瓣或三尖瓣或胸主动脉手术的 18 岁及以上的居民。排除长期护理居民、手术记录不一致的居民、以及在 90 天内接受透析或依赖呼吸机的居民。统计分析于 2021 年 7 月至 2022 年 1 月进行。
主要结局是患者定义的不良心血管和非心血管事件（PACE），定义为严重中风、心力衰竭、长期护理入院、新发透析和呼吸机依赖的复合结局。次要结局包括死亡率和单个 PACE 事件。使用考虑死亡为竞争风险的特定原因危害模型检查衰弱与 PACE 之间的关联，使用 Cox 模型检查衰弱与死亡之间的关联。在 10 年的随访中，为每个衰弱指标确定了接收者操作特征曲线（AUROC）的面积。
在 88456 名患者（22924 名女性[25.9%]；平均[标准差]年龄 66.3[11.1]岁）中，根据 ACG 标准，有 14935 名（16.9%）患者衰弱，63095 名（71.3%）患者根据 HFRS 标准衰弱，76754 名（86.8%）患者根据 PFI 标准衰弱。衰弱患者更可能年龄较大、为女性、来自农村地区；收入较低，合并症更多；并接受紧急手术。符合 ACG 标准的患者（危害比[HR]，1.66；95%CI，1.60-1.71）和 HFRS 评分较高的患者（每增加 1.0 分的 HR，1.10；95%CI，1.09-1.10）和 PFI 评分（每增加 0.1 分的 HR，1.75；95%CI，1.73-1.78）的 PACE 发生率更高。对于每个衰弱指标与死亡和个体 PACE 成分的关联，也观察到类似程度的关联。HFRS 在预测前 2 年的 PACE 和前 4 年的死亡方面具有最高的 AUROC，之后 PFI 具有最高的 AUROC。
这些发现可以帮助根据结局和随访时间调整衰弱指标的使用，从而优化术前风险分层、以患者为中心的决策、康复前候选者的选择以及心脏手术后患者的个性化监测和卫生资源规划。
