Using a multidimensional prognostic index (MPI) based on comprehensive geriatric assessment (CGA) to predict mortality in elderly undergoing transcatheter aortic valve implantation

    Using a multidimensional prognostic index (MPI) based on Comprehensive geriatric assessment (CGA) to predict mortality in elderly undergoing transcatheter aortic valve implantation Marie-Laure Bureau, Evelyne Liuu, Luc Christiaens, Alberto Pilotto, Jean Mergy, Fabienne Bellarbre, Pierre Ingrand, Marc Paccalin, Alfonso Cruz-Jentoft, Stefania Maggi, Francesco Mattace-Raso, Marc Paccalin, Maria Cristina Polidori, Daniele Sancarlo, Eva Topinkova, Gianluca Trifir`o PII: DOI: Reference:

S0167-5273(16)33465-9 doi: 10.1016/j.ijcard.2017.02.048 IJCA 24574

To appear in:

International Journal of Cardiology

Received date: Revised date: Accepted date:

8 November 2016 11 January 2017 13 February 2017

Please cite this article as: Bureau Marie-Laure, Liuu Evelyne, Christiaens Luc, Pilotto Alberto, Mergy Jean, Bellarbre Fabienne, Ingrand Pierre, Paccalin Marc, CruzJentoft Alfonso, Maggi Stefania, Mattace-Raso Francesco, Paccalin Marc, Polidori Maria Cristina, Sancarlo Daniele, Topinkova Eva, Trifir` o Gianluca, Using a multidimensional prognostic index (MPI) based on Comprehensive geriatric assessment (CGA) to predict mortality in elderly undergoing transcatheter aortic valve implantation, International Journal of Cardiology (2017), doi: 10.1016/j.ijcard.2017.02.048

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Using a multidimensional prognostic index (MPI) based on Comprehensive geriatric assessment (CGA) to predict mortality in elderly undergoing transcatheter aortic valve implantation

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Marie-Laure BUREAU, MD,1 Evelyne LIUU, MD,1 Luc CHRISTIAENS, MD, PhD,2 Alberto

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PILOTTO, MD, PhD,3 Jean MERGY, MD,2 Fabienne BELLARBRE, MD,1 Pierre INGRAND, MD, PhD,4,5 Marc PACCALIN, MD, PhD1,3 on behalf of the MPI_AGE Project Investigators

Pôle de Gériatrie, Centre Hospitalier Universitaire de Poitiers, Université de Poitiers,

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Poitiers, France; 2Service de Cardiologie, Centre Hospitalier Universitaire de Poitiers,

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Université de Poitiers, Poitiers, France ; 3Department of orthogeriatrics, Rehabilitation and Stabilitation – Frailty Area – E.O. Galliera Hospital, Hospital of National Relevance and

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High Specialization, 16128 Genoa, Italy. 4Pôle Biologie, Pharmacie et Santé Publique,

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Centre Hospitalier Universitaire de Poitiers, Université de Poitiers, Poitiers, France; INSERM, CIC-P 1402, Centre Hospitalier Universitaire de Poitiers, Université de

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Poitiers, Poitiers, France

EC funded MPI_AGE Project Investigators

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Alfonso Cruz-Jentoft, Hospital Universitario Ramòn y Cajal, Madrid, Spain; Stefania Maggi, EUGMS Representative and National Research Council, Neuroscience Section, Padova, Italy; Francesco Mattace-Raso, Erasmus Medical Center, Rotterdam, The Netherlands; Marc Paccalin, University Hospital of Poitiers, France; Maria Cristina Polidori, Head, Unit for Ageing Clinical Research Dpt. Medicine II, University Hospital of Cologne, Germany; Daniele Sancarlo, Geriatric-Gerontology Research Laboratory, IRCCS Casa Sollievodella Sofferenza, San Giovanni Rotondo, Foggia, Italy, Eva Topinkova, University Charles I, Prague, Czech Republic; Gianluca Trifirò, Erasmus Medical Center, Rotterdam, The Netherlands and University of Messina, Italy.

Address correspondence to Marie-Laure Bureau, MD, Pôle de Gériatrie, CHU La Milétrie, 86021 Poitiers Cedex, France. E-mail: [email protected] Tel: +33 5 49 44 38 41; Fax: +33 5 49 44 44 29 ;

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ACCEPTED MANUSCRIPT Or Marc Paccalin, MD, PhD, Pôle de Gériatrie, CHU La Milétrie, 86021 Poitiers cedex, France. E-mail: [email protected]; Tel: +33 5 49 44 44 27; Fax: +33 5 49 44 44

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Conflicts of interest: none

Funding source: This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.

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Support: This work was supported by the MPI_AGE European project co-funded by the Executive Agency for Health and Consumers (EAHC) in the frame of the European

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Innovation Partnership on Active and Healthy Ageing Second Health Programme 20082013. The contents of this paper are the sole responsibility of the above mentioned

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Authors and can under no circumstances be regarded as reflecting the position of the

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European Union.

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Abbreviated title: FRAILTY and TAVI Figures and tables: 2 figures and 3 tables

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Key words: transcatheter aortic valve implantation; elderly; prognosis; mortality; multidimensional prognostic index

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ACCEPTED MANUSCRIPT ABSTRACT Background: Selection of appropriate elderly who can benefit from transcatheter aortic valve

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implantation (TAVI) is challenging. We evaluated the prognosis of this procedure according

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to the comprehensive geriatric assessment (CGA) based on the multidimensional prognostic

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index (MPI).

Methods: Prospective observational monocentric study from January 2013 to December

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2015. Consecutive patients aged ≥75 who underwent TAVI and a complete CGA were included. Baseline demographic, geriatric and cardiologic data were collected. CGA was used

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to calculate the MPI score that is divided in three groups according to the mortality risk. Follow up was performed until December 2016 and mortality rate was assessed at one, six

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and 12 months.

Results: 116 patients were included. Mean age was 86.2±4.2 years, mean European system

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for cardiac operative risk evaluation (EuroSCORE) was 19.2±11.3%, mean MPI score was 0.39±0.13. Forty-five (38.8%) patients belonged to MPI-1 group, 68 (58.6%) to MPI-2 group

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and three to MPI-3 group. MPI score and Euroscore were moderately correlated (Spearman correlation coefficient rs = .27, p= .0035). Mortality rate was significantly different between MPI groups at six and 12 months (p= .040 and p= .022). Kaplan Meier survival estimates at one year stratified by MPI groups was significantly different (hazard ratio HR = 2.83, 95%confidence interval (CI) 1.38-5.82, p= .004). Among variables retained to perform logistic regression analysis, the score of instrumental activities of daily living appeared the most relevant (p< .001). Conclusion: This study indicates that CGA based on MPI tool is accurate to predict prognosis in elderly patients undergoing TAVI procedure.

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ACCEPTED MANUSCRIPT ABREVIATIONS ADL: activities of daily living

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CGA: comprehensive geriatric assessment

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CIRS: Cumulative Illness Rating Scale ESS: Exton-Smith Scale

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IADL: instrumental activities of daily living

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EuroSCORE: European system for cardiac operative risk evaluation

MACCE: Major adverse cerebral and cardiovascular events

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MMSE: Mini Mental State Examination

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MNA-SF: Mini Nutritional Assessment-Short Form

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MPI: Multidimensional prognostic index SAVR: surgical aortic valve replacement

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SPMSQ: Short Portable Mental Status Questionnaire STS score: Society of Thoracic surgeons score TAVI: transcatheter aortic valve implantation

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ACCEPTED MANUSCRIPT 1.

INTRODUCTION:

The prevalence of severe aortic stenosis in patients over 75 years of age is up to 3.4%, among

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which 75% are symptomatic with a bad prognosis1–3. Many patients are unsuitable candidates

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for surgical aortic valve replacement (SAVR) because of their comorbidities and general health status4,5. In such patients, transcatheter aortic valve implantation (TAVI) appears to be a less-invasive and valuable alternative treatment6–9. However, selection of appropriate

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patients who can benefit from TAVI is a challenge and requires collaboration between cardiologists and geriatricians. The logistic European System for Cardiac Operative Risk

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Evaluation (EuroSCORE) and the Society of Thoracic surgeons (STS) score are mainly used to assess the cardiac operative risk and determine the eligibility for TAVI10,11. However, these

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scores appear suboptimal when evaluating older patients with severe aortic stenosis12,13.

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Geriatric assessment is now a routine practice and the impact of the patients’ frailty status on

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the prognosis after TAVI is increasingly described14–17. The multidimensional prognostic index (MPI) based on comprehensive geriatric assessment (CGA) predicts mortality in elderly

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patients with heart failure and other chronic conditions18,19. The objective of our study was to assess the prediction of this tool on the prognosis after the TAVI procedure.

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2.

METHODS Population

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2.1.

From January 2013 to December 2015, all patients aged 75 years and older referred for TAVI

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to the cardiovascular unit of Poitiers University Hospital, were screened and systematically evaluated by the geriatric team according to the French recommendations. The comprehensive

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geriatric assessment was performed during a planned specific consultation using the

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multidimensional prognostic index (MPI)18,19.

The baseline demographic data and the cardiologic evaluation were recorded. Only patients with complete CGA and who underwent TAVI were included.

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All patients provided written informed consent. The protocol was approved by the ethical

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committee of our institution.

Comprehensive geriatric assessment

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The MPI is based on a standardized CGA and includes eight domains, i.e., medications, living status and six standardized scales19 (table 1). The functional status is assessed using activities of daily living (ADL) ranging from 0 (total dependence) to 6 (independence)20 and instrumental activities of daily living (IADL) ranging from 0 (total dependence) to 8 (independence)21. Nutritional status is evaluated by the Mini Nutritional Assessment-Short Form (MNA-SF)22, MNA-SF ≤ 7 indicating malnutrition, [8-11] a risk of malnutrition and ≥ 12 a normal nutritional status. The Short Portable Mental Status Questionnaire (SPMSQ) is used to evaluate the cognitive function and scores the number of errors23: cognitive impairment is defining as major when the number of errors is ≥ 8, minor between 4 and 7 errors, and absent when the number of errors is ≤ 3. Comorbidity is assessed using the 6

ACCEPTED MANUSCRIPT Cumulative Illness Rating Scale (CIRS)24. The CIRS uses a 5-points ordinal scale to estimate the severity of organ pathology (score 0 to 4, the higher the more severe) in each of the

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following systems: cardiac, vascular, respiratory, eye-ear-nose-throat, upper and lower

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digestive tract, hepatic, renal, genitourinal, musculoskeletal, skin, nervous, endocrine-

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metabolic, and psychiatric. The Co-morbidity Index (CIRS-CI) concerns the number of organ pathologies that are quoted moderate or severe (score 2 to 4). The Exton-Smith Scale (ESS) determines the risk of pressures sores, ranging from 5 (high risk) to 20 (minimum risk)25.

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Living status is divided in three parts: living with family, institutionalized and alone. Number

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of medication is ranged in three groups: ≤3, from 4 to 6 and ≥ 7 drugs a day. In each domain cited above, a value is determined according to the conventional cutoff points

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(table 1). Value=0 indicates no problem, 0.5 minor problem and 1 major problem. For

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example, if patient is independent for 5 or more functional activities, ADL value to calculate MPI = 0 indicating no problem; if patient is independent for 3 or 4 activities, ADL value = 0.5

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indicating minor problem; if patient is independent for 2 or less functional activity, ADL value = 1 indicating major problem. The sum of all domain values is then divided by 8 to

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obtain the final MPI score. The MPI score is divided into three levels of mortality risk: with MPI-1 (≤0.33) indicating low risk, MPI-2 (0.34-0.66) a moderate risk and MPI-3 (≥0.66) high risk of mortality19.

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Follow up and outcomes measures

A systematic follow up was performed. Patients were scheduled for echography evaluation one month and one year after TAVI by the interventional cardiologists, and clinical evaluation was performed during a planned specific consultation at 6 months and 1 year by the geriatricians. All cause of mortality at one month, six months and one year as well as major adverse cerebral and cardiovascular events (MACCE) were assessed. MACCE include stroke, 7

ACCEPTED MANUSCRIPT myocardial infarction, major bleeding and major vascular complication according to the Valve Academic Research Consortium Criteria, occurring during the 30 days following the

Statistical analysis

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2.4.

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intervention 26.

Descriptive statistics were expressed as means ± standard deviations for continuous variables

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or absolute number and percentages for categorical variables. Univariate analyses of the association between the measured data and postoperative mortality at 1, 6 and 12 months used

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the Fisher’s exact test or Wilcoxon rank-sum test. A p value <0.05 was considered to be statistically significant. A logistic regression was used for multivariate analysis of

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postoperative mortality. Univariate survival analysis used the log rank test and Cox regression

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was used for multivariable analysis. Multivariable logistic and Cox survival analyses used a stepwise elimination procedure retaining all variables proposed for the univariate analysis,

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those variables were significant at the multivariate p< .10 level. Correlation between EuroSCORE and MPI scores was estimated by the Spearman Correlation Coefficient (rS). All

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analyses were performed with SAS 9.4 software (Cary NC, USA).

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RESULTS

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Two hundred and twenty five patients were screened and 116 (49.1% women) were

Patients’ characteristics

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3.1.

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considered for our study by December 2015 (Figure 1).

The mean age was 86.2 ± 4.2 years (range, 75-100). Fifty (43.1%) patients were considered to

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have a high surgical risk according to a logistic EuroSCORE ≥ 20%. The left ventricular ejection fraction was preserved (> 50%) in eighty (69.0%) patients (table 2). Eighty percent of

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the patients underwent the TAVI procedure within 2 months after GCA and all geriatric evaluations were performed less than six months before the procedure.

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Almost 80% of patients had at least three comorbidities requiring specific treatment and

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almost 70% were polymedicated (≥ 7 drugs). Over half of patients (51.7%) were at risk of

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malnutrition or malnourished (MNA-SF < 12), scarcely 20% were cognitively impaired according to SPMSQ (> 3 errors), and 10% had abnormal ADL score (<5). Mean MPI score was 0.39 ± 0.13. According to the MPI score, 45 (38.8%) patients belonged

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to the MPI-1 group (mean value 0.26 ± 0.05), 68 (58.6%) to the MPI-2 group (mean value 0.45 ± 0.08) and three patients (2.6%) to the MPI-3 group (mean value 0.77 ± 0.07). MPI-score and EuroSCORE were moderately correlated (rS = 0.27; p = .0035).

3.2.

Follow-up at one month

The total mortality rate one month after TAVI was 9.5% (11 patients): four deaths (8.9%) in MPI-1 group, six (8.8%) in MPI-2 group and one (33.3%) in MPI-3 group, among which seven (63.6%) occurred during the procedure or within 24 hours. There was no significant difference in the 30-day mortality rate between the groups. MACCE occurred in 20.0% of patients, eight (17. 8%) patients in MPI-1 group, and 14 (20.6%) in MPI-2 group. Neither 9

ACCEPTED MANUSCRIPT EuroSCORE (p = .80), nor MPI score (p = .70) were associated with MACCE and there was

Mortality at six month

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no difference between the MPI groups (p = .89).

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The mortality rate six month after TAVI was 14.7%. Respectively 8.9% (four deaths), 16.2% (11 deaths) and 66.7% (two deaths) in MPI -1, MPI -2 and MPI-3 group, showing a

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significant difference with Fisher’s exact test (p = .040). In univariate analysis, vital status six months after TAVI was significantly associated with baseline MPI score, ADL, IADL and

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MNA-SF scores but not with EuroSCORE (table 3). In multivariate logistic regression

Mortality at 12 months

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analysis, MNA-SF was associated with six months mortality.

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Five patients were lost to follow-up before 12 months. In 111 analysed patients, the mortality rate was 19.8%, respectively 9.5% (four deaths), 24.2% (16 deaths) and 66.7% (two deaths) in MPI-1, MPI-2 and MPI-3 groups, showing a significant difference with Fisher’s exact test (p

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= .022). In univariate analysis, vital status six months after TAVI was significantly associated with IADL and MNA-SF scores (table 3). In multivariate logistic regression analysis, sex, Euroscore, IADL and MNA-SF were associated with twelve months mortality.

3.5.

Survival analysis

As only three patients belonged to the MPI-3 group, we combined this group with MPI-2 group (MPI-2+3) for this analysis. The median follow-up was 14.8 months. A follow-up was available for 100% of the cohort at 6 months and for 93% at 12 months. The estimated survival rate at one year was 91.1 ± 4.2% in MPI-1 group and 74.4 ± 4.2% in the pooled MPI-

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ACCEPTED MANUSCRIPT 2+3 group (logrank test p = .0046) (Figure 2). A significant difference in survival was also found for IADL (p < .001), MNA-SF (p < .001) and EuroSCORE (p = .018). In multivariate

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Cox regression analysis, sex (p = .084), IADL (p < .001) and MNA-SF (p = .036) were

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independently related to prognosis.

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ACCEPTED MANUSCRIPT 4.

DISCUSSION

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Selection of the elderly patients unsuitable for SAVR who will benefit the most from TAVI is

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a challenge. MPI tool appears to be useful to select the most appropriate candidate as MPI-1

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patients had a higher survival (p = .0046).

Patients included in our study were old with a high prevalence of comorbidities, polymedication, and risk of malnutrition. The mortality rate at one month was 9.5% and

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14.7% at six month and 19.8% at one year. This mortality rate after TAVI is similar to those reported in previous studies, from 6% to 13% at one month and 19 to 33% at one year,

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depending on age and technical approach.

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The lack of association between the MPI score and the short term mortality may have several

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significations. First it suggests the adequacy of the selection process to identify patients at

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higher risk for periprocedural complications after TAVI; i.e., the low sample size of patients

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in MPI-3 group indicates that the cardiologic criteria to select patients for TAVI, exclude the most frail patients. Secondly, according to literature data, evaluation of frailty in the elderly

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with aortic stenosis seems to usually impact more on long-term than on short-term mortality14–

Only one prospective study assessing the impact of CGA to improve the prognostic accuracy of patients undergoing TAVI, developed a frailty index which was associated with mortality and major adverse cardiovascular and cerebral events 30-days after TAVI. 36. The frailty index and all the CGA-items used in this index (including ADL, MNA, mobility and MMSE) except IADL were independently associated with mortality at one month and one year. Green and al assessed the accuracy of another frailty index on prognosis after TAVI 15. This frailty index including gait speed, grip strength, serum albumin, and ADL was associated with increased mortality one year after TAVI when modeled continuously and divided, but not

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ACCEPTED MANUSCRIPT associated with procedural outcomes (including one month mortality). When this index was extended to a larger multi center population, in a substudy of the PARTNER trial, there was

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neither any association with major adverse clinical events one month after TAVI but the

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frailty index was associated with poor outcomes at 6 month and one year 33 .

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In a recent study, Chetan and al evaluated the impact of frailty on outcomes after TAVI35. The frailty assessment included shrinking, weakness, slowness, and low physical activity. There was no difference in post TAVI 30-days mortality and major adverse outcomes between the

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groups of frailty.

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The frailty index used were not totally the same but shared some common parameters mainly the evaluation of the autonomy (ADL) and malnutrition. In our study, IADL and MNA-SF were more relevant than other variables to assess the prognosis after the procedure and

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significantly associated with mortality in most analysis. An explication could be that the evaluation of autonomy in this population was more heterogeneous with IADL than with

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ADL, probably because in the course of time ADL dependence appears later. Indeed almost 90% of patients presented none or only one dependence in ADL at baseline. Many approaches

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have been used to assess frailty and the optimal instrument is unknown in elderly with aortic stenosis. The GCA-based MPI shows prognostic accuracy that is significantly higher than other tools based on frailty instruments. This was shown for all-cause mortality in a large cohort of hospitalized older patients. MPI was compared to 3 frailty indexes: one derived from the Study of Osteoporotic Fractures (FI-SOF), one based on the cumulative deficits model (FI-CD), and one based on a comprehensive geriatric assessment (FI-CGA). Still evaluation of the mobility is not included in the MPI score, and the impact of gait speed on the prognosis in elderly patients undergoing cardiac surgery is increasingly described38–40. The benefit of preoperative geriatric assessment and CGA in hospitalized elderly patients is wide and has been demonstrated in other pathologies41,42. CGA detects modifiable risk factors 13

ACCEPTED MANUSCRIPT amenable before intervention, also helps detecting cognitive impairment, preventing postoperative delirium, and allows a re-evaluation of prescriptions. Furthermore some

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previous investigations suggest that frailty assessment is associated not only with mortality

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after TAVI but also with functional decline14,33.

Limitations:

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First, the low sample size in MPI-3 group (3% of inclusion) does not permit to draw any

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conclusion about the prognosis after TAVI in this group. Although EuroSCORE and MPI score were not strongly correlated, this shows that cardiologic assessment excludes the most

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frail patients from TAVI procedure.

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Second, these results are based on a small sample from a single center experience.

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5.

CONCLUSION

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The typical geriatric profile of patient undergoing TAVI in this study is an 87 years old

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patient with severe comorbidities and polymedication, cognitively competent, living at home,

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independent in activity of daily living and at risk of malnutrition. Frailty assessed by CGAbased MPI score was associated with long term mortality, but not with short term mortality or

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MACCE. The results of our study highlight the usefulness of geriatric assessment before TAVI procedure and suggest the accuracy of CGA based on MPI tool to predict the prognosis

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in elderly with aortic stenosis.

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35. Huded CP, Huded JM, Friedman JL, et al. Frailty Status and Outcomes After Transcatheter Aortic Valve Implantation. Am J Cardiol 2016;117(12):1966–71.

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36. Stortecky S, Schoenenberger AW, Moser A, et al. Evaluation of multidimensional geriatric assessment as a predictor of mortality and cardiovascular events after transcatheter aortic valve implantation. JACC Cardiovasc Interv 2012;5(5):489–96.

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37. Pilotto A, Rengo F, Marchionni N, et al. Comparing the prognostic accuracy for all-cause mortality of frailty instruments: a multicentre 1-year follow-up in hospitalized older patients. PloS One 2012;7(1):e29090.

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38. Afilalo J, Eisenberg MJ, Morin J-F, et al. Gait speed as an incremental predictor of mortality and major morbidity in elderly patients undergoing cardiac surgery. J Am Coll Cardiol 2010;56(20):1668–76.

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39. Green P, Woglom AE, Genereux P, et al. Gait speed and dependence in activities of daily living in older adults with severe aortic stenosis. Clin Cardiol 2012;35(5):307–14.

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40. Lilamand M, Dumonteil N, Nourhashémi F, et al. Gait speed and comprehensive geriatric assessment: two keys to improve the management of older persons with aortic stenosis. Int J Cardiol 2014;173(3):580–2. 41. Ellis G, Whitehead MA, Robinson D, O’Neill D, Langhorne P. Comprehensive geriatric assessment for older adults admitted to hospital: meta-analysis of randomised controlled trials. BMJ 2011;343:d6553. 42.

Dewan SK, Zheng SB, Xia SJ. Preoperative geriatric assessment: comprehensive, multidisciplinary and proactive. Eur J Intern Med 2012;23(6):487–94.

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ACCEPTED MANUSCRIPT

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225 patients eligible for TAVI

81 not included

18 surgical aortic valve replacement 48 medical option or refusal 8 waiting for TAVI procedure 7 deaths before TAVI procedure

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   

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144 patients underwent TAVI

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Figure 1. Flow Chart

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116 patients included

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28 excluded because of uncomplete CGA

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ACCEPTED MANUSCRIPT Table 1. Multidimensional Prognostic Index Score Assigned to Each Domain Based on the Severity of the Problem

6-5

IADL

8-6

SPMSQa CIRS-CIb

2-0

5-4

3-0

0-3

4-7

8-10

0

1-2

≥3

≥ 12

8-11

≤7

16-20

10-15

5-9

0-3

4-6

≥7

Living with family

Institutionalized

Living alone

NU

MNA- SF score ESS score

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Number of medications

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Social support network

Severe problem (value = 1)

4-3

SC R

ADL

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Assessment

Minor problem (value = 0.5)

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No problem (value = 0)

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ADL: Activities of Daily Living; IADL: Instrumental Activities of Daily Living. Number of active functional activities (the higher the score, the more independent).

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SPMSQ: Short Portable Mental Status Questionnaire aNumber of errors. CIRS-CI: Cumulative Illness Rating Scale Comorbidity Index bNumber of diseases. Mini Nutritional Assessment Short Form

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ESS: Exton Smith Scale

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ACCEPTED MANUSCRIPT Table 2. Baseline Patients Characteristics (N=116)

Parameters Cardiologic data mean score

Results (N= 116) 19.2 ± 11.3 56.6 ± 15.4 0.72 ± 0.16 51.1 ± 18.8

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EuroSCORE (%) LVEF (%) Aortic valve area (cm2) Mean gradient aortic valve (mmHg) NYHA functional class I 18 (15.5%) II 48 (41.4%) III 47 (40.5%) IV 3 (2.6%) SPMSQ 0-3 errors 96 (82.8%) Geriatric assessment 4-7 errors 18 (15.5%) scores 8-10 errors 2 (1.7%) ESS 16-20 105 (90.5%) 10-15 10 (8.6%) 5-9 1 (0.9%) ADL 5-6 104 (89.7%) 3-4 9 (7.8%) 0-2 3 (2.6%) IADL 6-8 48 (41.4%) 4-5 44 (37.9%) 0-3 24 (20.7%) CIRS index 0 0 (0%) 1-2 17 (14.7%) ≥3 99 (78.6%) MNA-SF ≥ 12 56 (48.3%) 8-11 55 (47.4%) ≤7 5 (4.3%) Number of drugs 0-3 drugs 3 (2.6%) 4-6 drugs 33 (28.5%) ≥ 7 drugs 80 (69.0%) Living status With family 54 (46.6%) institutionalized 18 (15.5%) alone 44 (37.9%) LVEF =left ventricular ejection fraction; NHYA = New York Heart Association; CIRS = Cumulative Illness Rating scale; MNA-SF = Mini Nutritional Assessment short-form; SPMSQ = Short Portable Mental Status Questionnaire; ESS = Exton-Smith Scale; ADL = activity of daily living, IADL = instrumental activity of daily living.

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ACCEPTED MANUSCRIPT Table 3. Univariate and multivariate analysis according to mortality at six months and 12 months.

Alive

Dead

(n = 89)

Age (year)

86.1 ± 4.3

86.4 ± 4.2

.78

86.5 ± 4.3

85.4 ± 4.4

.28

Sexe: female (%)

52 (52.5%)

5 (29.4 %)

.11

51 (57.3 %)

6 (27.3 %)

.16

MPI score

0.37 ± 0.12

0.46 ± 0.16

.044

0.37 ± 1.12

0.44 ± 0.15

.055

EuroSCORE

18.4 ± 10.3

23.9 ± 15.2

.17

17.6 ± 9.3

24.4 ± 14.8

.051

CIRS index

4.0 ± 1.5

4.1 ± 1.2

.65

3.9 ± 1.4

85.4 ± 4.4

.27

ADL

5.5 ± 0.9

4.8 ± 1.7

.048

5.5 ± 0.9

5.0 ± 1.5

.22

5.3 ± 2.0

3.7 ± 2.5

.010

5.5 ± 1.9

3.5 ± 2.3

.0002

7.6 ± 2.4

8.1 ± 2.1

.38

7.7 ± 2.4

8.2 ± 2.3

.28

11.3 ± 1.9

9.8 ± 2.3

.009

11.4 ± 1.9

10.0 ± 2.4

.013

SPMSQ

1.6 ± 1.6

2.2 ± 2.2

.42

1.6 ± 1.7

2.2 ± 2.0

.19

ESS

18.4 ± 1.7

17.1 ± 3.0

.063

18.5 ± 1.7

17.4 ± 2.8

.098

Habit us

With family

44 (44.4%)

10 (58.8 %)

38 (42.7 %)

13 (59.1 %)

institutionali zed

14 (14.1%)

4 (23.5 %)

13 (14.6 %)

4 (18.2 %)

Alone

41(41.4

3

38

5

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MNA-SF

P

.057

.15

.065

.024

(n = 22)

IP

(n = 17)

Number of drugs

Multivari ate

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(n = 99)

IADL

Univari ate

NU

Dead

MA

Alive

Mortality at 12 months

T

Mortality at 6 months

Univari ate

Multivari ate

P

P

.0059

.063

.0061

.078

.20

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(17.7 %)

(42.7 %)

(22.7 %)

Descriptive statistics as mean±SD or n (%)

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CIRS = Cumulative Illness Rating scale; MNA-SF = Mini Nutritional Assessment short-form; SPMSQ = Short Portable Mental Status Questionnaire; ESS = Exton-Smith Scale; ADL = activity of daily living, IADL = instrumental activity of daily living; SD = standard deviation

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