Frailty and pre-frailty in cardiac surgery: a systematic review and meta-analysis of 66,448 patients

Abstract

Background The burden of frailty on cardiac surgical outcomes is incompletely understood. Here we perform a systematic review and meta-analysis of studies comparing frail versus pre-frail versus non-frail patients following cardiac surgery. Methods We searched MEDLINE and EMBASE databases until July 2018 for studies comparing cardiac surgery outcomes in “frail”, “pre-frail” and “non-frail” patients. Data was extracted in duplicate. Primary outcome was operative mortality. Results There were 19 observational studies with 66,448 patients. Frail patients were more likely female (risk ratio [RR]1.7; 95%CI:1.5–1.9), older (mean difference: 2.4; 95%CI:1.3–3.5 years older) with greater comorbidities and higher STS-PROM. Frailty (RR2.35; 95%CI:1.57–3.51; p < 0.0001) and pre-frailty (RR2.03; 95%CI:1.52–2.70; p < 0.00001) were associated with increased operative mortality compared with non-frail patients. Frailty was also associated with greater risk of prolonged hospital stay (RR1.83; 95%CI:1.61–2.08; p < 0.0001) and intermediate care facility discharge (RR2.71; 95%CI:1.45–5.05; p = 0.002). Frail (Hazard Ratio [HR]3.27; 95%CI:1.93–5.55; p < 0.0001) and pre-frail patients (HR2.30; 95%CI:1.29–4.09; p = 0.005) had worse mid-term mortality (median follow-up 1 years [range 0.5–4 years]). After adjustment for baseline imbalances, frailty was still associated with greater operative mortality (odds ratio [OR]1.97; 95%CI:1.51–2.57; p < 0.00001), intermediate care facility discharge (OR4.61; 95%CI:2.78–7.66; p < 0.00001) and midterm mortality (HR1.37; 95%CI:1.03–1.83; p = 0.03). Conclusion In patients undergoing cardiac surgery, frailty and pre-frailty were associated with 2-fold and 1.5-fold greater adjusted operative mortality, respectively, greater adjusted perioperative complications and frailty was associated with almost 5-fold risk of non-home discharge. Graphical abstract Burden of frailty and pre-frailty on cardiac surgical outcomes.

Slow gait speed is associated with worse postoperative outcomes in cardiac surgery: A systematic review and meta‐analysis

“…The clinical implication of our findings is important for surgical planning and decision making. Several studies included in the current review 8,10 and previous systematic reviews 2,18 highlight that gait speed, and thus in the broader sense, frailty, portend postoperative mortality, and morbidity even after adjusting for traditional risk scores such as STS mortality score and euroSCORE. In their systematic review, Li et al 19 expanded on this notion and reported that the addition of frailty to pre-existing risk models improved mortality prediction.…”

“…The strength of our study is the consistency in our definition of frailty as measured by slow gait speed. Previous reviews have acknowledged a lack of universally accepted definition for frailty and the resultant heterogeneity 2,15,16 . To date, at least 15 different frailty tools have been used to examine the effects of frailty on outcomes in patients undergoing cardiac surgery alone 2 .…”

“…Previous reviews have acknowledged a lack of universally accepted definition for frailty and the resultant heterogeneity 2,15,16 . To date, at least 15 different frailty tools have been used to examine the effects of frailty on outcomes in patients undergoing cardiac surgery alone 2 . Gait speed is a validated marker of frailty that is objective, easy, quick, inexpensive, and reproducible.…”

“…1 Evidence is clear that frailty, measured by various frailty assessment tools, is associated with poorer outcomes in patients undergoing cardiac surgery. 2,3 With increasing body of evidence around frailty and poorer postoperative outcomes, it is important to focus on a single validated frailty tool in the cardiac patient cohort.…”

Frailty Syndrome in Older Adults with Cardiovascular Diseases–What Do We Know and What Requires Further Research?

“…Frailty syndrome is also associated with postoperative complications after cardiac surgery. Postoperative complications in patients after scheduled coronary artery bypass surgery were reported in 17% of patients without identified FS, 28% of patients with identified pre-frail condition and 56% of patients with FS regardless of chronological age [ 51 ]. A meta-analysis showed that FS and pre-frailty were associated with greater adjusted operative mortality and adjusted perioperative complications, and FS was associated with almost 5-fold risk of non-home discharge [ 49 ].…”