Editorial
Cardiac surgery in octogenarians: Have we gone too far. . .or not far enough? Jonathan E. E. Yager, MD, and Eric D. Peterson, MD, MPH Durham, NC
See related article on page 347.
Jonathan Swift is quoted as having said “All men desire to live long. . .yet no man would be old.” The modern day example of this paradox can be seen in issues of cardiac surgery in very elderly patients. On one hand, clinicians have an obligation to do all they can to extend life. On the other hand, is there not an age at which point a procedure’s likelihood for “meaningful benefit” is outweighed by its acute risks and possibility of prolonged disability? In this issue of the Journal, Rady and Johnson seem to have concluded that this threshold for cardiac surgery is reached at or around age 80 years. However, before we conclude that modern medicine has gone “too far,” further illumination of the issues is required. Rady and Johnson compared results of cardiac surgery in 97 patients who were octogenarians with results seen in younger patients treated at a single tertiary care center. Relative to younger patients, patients who were octogenarians faced significantly higher risks for inhospital death (13.5% vs 1.3%), re-operation (7% vs3%), renal insufficiency (7% vs 1%), and neurological complications (6% vs 2%). Patients who were octogenarians used more hospital resources, with significantly longer stays in the intensive care unit (⫹0.7 days, P ⬍.001) and total hospital stays (⫹1.9 days, P ⬍.002). Additionally, the authors found that 40% of patients who were octogenarians and survived were discharged to a nursing care facility, as compared with 13% of younger patients. Because all patients were living independently before surgery, the authors conclude that discharge to a nursing care facility represented a significant deterioration in quality of life. The authors should first be praised for their openness in reporting this case series. Too often centers are willing to publish clinical experiences only when their results are exceptional. As such, patients and practitioners can get skewed estimates of procedural results that understate treatment risks while exaggerating the benefits. Second, the authors are commended
From the Duke Clinical Research Institute, Durham, NC. Reprint requests: Eric D. Peterson, MD, MPH, Duke Clinical Research Institute, PO Box 17969, Durham, NC 27715. Am Heart J 2004;147:187–9. 0002-8703/$ - see front matter © 2004, Elsevier Inc. All rights reserved. doi:10.1016/j.ahj.2003.08.006
for considering the important issue of longer-term functional outcomes after a procedure. Although surviving to hospital discharge is be considered a “technical success,” patients may challenge its value when they leave with significant disability and loss in independence. Although this paper raises important points about the risks of cardiac surgery in very elderly patients, the study itself has limitations. First, the study represents a single center’s experience and a small sample size. Because of this, the authors chose to combine patients undergoing valve or combined procedures with isolated bypass grafting cases. Because the operative risks vary considerably for these different procedure types, it would have been helpful to have seen outcomes broken down by these different operations. Part of the higher risks of “cardiac surgery” in patients who are octogenarians is caused by their undergoing valve or combined procedures 48% of the time (vs 22% in younger patients). Larger, multicenter studies of both bypass graft and valve surgery in elderly patients have been published. A review of national bypass graft surgery in patients who were octogenarians from 1994 through 1997 (n ⫽ 64,476 for coronary artery bypass grafting [CABG] alone and 3297 for combined CABG/ valve surgery) reported that the inhospital mortality rates in patients who were octogenarians ranged from 8.1% for isolated CABG to 19.6% for combined CABG/ mitral valve surgery.1 Since then, surgical risks in very elderly patients have continued to fall with ongoing advances in the field and increasing surgical experience. Data from the Society of Thoracic Surgeons’ National Cardiac Database from 2000 to 2003 reveal an operative mortality rate of 6.5% for isolated bypass grafting in patients aged ⱖ80 years (n ⫽ 35,761) and 10.9% for patients who were octogenarians and receiving a valve only or combined bypass graft plus valve surgery (n ⫽ 19,325) (Peterson E for the Society of Thoracic Surgeons’ National Cardiac Database, personal communication). A second limitation of the current study is its ability to clarify how procedural risks varied as a function of patients’ preoperative clinical factors. Although age alone does lead to higher procedural risks, it is but 1 factor that is predictive of surgical outcomes. Patients with similar age (including octogenarians) can face vastly different surgical risks depending on other clinical factors. For example, Alexander noted that when isolated bypass graft surgery was performed in elderly
188 Yager and Peterson
patients without comorbidities, the mortality rate was 4.2%, which approaches that seen in younger patients.1 Third, the percentage of patients requiring transfer to a nursing care facility (40% of the inhospital survivors) is significantly higher in the present study than in other published reviews. Glower et al found that 89% of surviving patients who were octogenarians were discharged home after bypass graft surgery.2 In another study of 121 patients who were octogenarians and undergoing cardiac surgery, 92% of the patients who survived at late follow-up were living at home, and 6.6% were living in a nursing home.3 The reasons for these differences in the studies most likely represent differential discharge planning strategies. Specifically, certain centers use short-stay nursing facilities as an intermediate rehabilitation setting before returning elderly patients to their home environment. This care strategy can allow elderly patients more time to fully recover while simultaneously reducing length-of-stay at the more resource-intensive acute care hospital. Unfortunately, the current study does not provide us with data on how long the patients spent in the nursing home nor does it provide long-term functional outcomes of its patients. Thus, a high transfer rate to rehabilitation settings seen in this study may reflect a positive sign— encouraging physical independence and consequently higher long-term quality of life in their elderly patients, as opposed to signifying a “significant deterioration in quality of life.” Finally, the authors rightly discuss the need to consider how surgical outcomes stack up against other treatment options in elderly cardiac patients. Comparing the unadjusted outcomes of surgery in patients who are octogenarians and have coronary disease versus those treated with conservative medical care finds that by 1 year 81% of the patients treated with surgery will be alive, compared with 74% of the patients treated with medicine. By 3 years, these survival rates were 74% for patients treated with surgery and 55% for patients treated medically.4 Although these results are influenced by the treatment selection biases, it does bring to mind Maurice Chevalier’s saying that “Old age (or surgery in old age patients) isn’t so bad when you consider the alternative.” Recent studies are beginning to give us some insight on adjusted treatment comparisons. The Alberta Provincial Project for Outcomes Assessment in Coronary Heart Disease (APPROACH) registry conducted a well done study looking at outcomes after cardiac catheterization in patients aged ⱖ80 years. At 4 years, the adjusted survival rate was 77% in patients undergoing bypass grafting, 72% in patients undergoing percutaneous intervention (PCI), and 60% for patients treated with medical therapy.5 Most recently, the Trial of Invasive Versus Medical Therapy in Elderly Patients with
American Heart Journal February 2004
Chronic Symptomatic Coronary Artery Disease (TIME) trial randomized patients age ⱖ75 years to receive medical therapy or an invasive strategy including both CABG and PCI. They found that patients treated in the invasive arm of the study had fewer major adverse cardiac events, improved angina, and improved quality of life when compared with patients treated medically at 6 months.6 By 1 year, however, some of these differences had narrowed, yet there was a reduced need for re-hospitalization and re-vascularization in patients treated in the invasive arm of the study.7 Although certain of the authors’ conclusions seen unsubstantiated, few would argue with their calls for more research on this important topic. As the population continues to age, we can anticipate with increasing frequency the decision of whether to have patients who are octogenarians undergo CABG. Furthermore, the technological playing field is changing. The use of off-pump surgery (without cardiopulmonary bypass grafting) is increasing in frequency and has been shown to reduce neurological complications.8 Newer drug-eluting stents are also changing the field of PCI and reducing the need for repeat procedures. Secondary prevention measures, including better use of evidence-based medications such as -blockers, angiotensin-converting enzyme inhibitors, and lipid-lowering therapy, are improving also. In this setting, ongoing evaluation is sorely needed, with further randomized trials that specifically include elderly patients, a group that has been severely under-represented to date. Finally, as we await the results of these ongoing trials, we would also agree with Rady and Johnson that communication to patients (both young and old) needs to be improved. One study of patients undergoing cardiac catheterization demonstrates that 82% seek an active or collaborative role in their medical decisionmaking and 93% desire information about their procedure. Of these patients who went on to undergo CABG, at 6 weeks postoperatively, 22% could not recall what benefits were explained to them before their surgery. Twenty-eight percent of these patients could not recall what risks were explained, and 57% of these patients could not recall the magnitude of the risks. Elderly patients were less likely to recall risks than were younger patients, as were women, non-white patients, and patients with less education.9 Although providing the risks and benefits of procedures and those for alternative treatment options is a main tenet of the informed-consent process, we are failing to do this successfully for a large proportion of our patients. Ideally, we should be providing patients with “evidence-based” estimates reflecting not only the individual patient’s age, but also their other clinical and confounding comorbid issues. These should include both estimates of acute risk from the procedure and longterm functional outcome.
American Heart Journal Volume 147, Number 2
Rady and Johnson have provided some sobering data that causes us to reconsider whether our current patterns of invasive cardiac care in patients who are octogenarians have gone too far. Although it seems too early to conclude this, we can safely infer that we are doing too littleѧtoo little research on the topic and too little dialog with our patients on the real risks and benefits of procedures. Future efforts should be directed both at determining procedure-associated risks for elderly patients and at communicating that risk with them. It is our role as providers to assist our patients, young and old, with making difficult, important, and informed therapeutic decisions.
References 1. Alexander KP, Anstrom KJ, Muhlbaier LH, et al. Outcomes of cardiac surgery in patients aged ⱖ80 years: results from the National Cardiovascular Network. J Am Coll Cardiol 2000;35:731– 8.
Yager and Peterson 189
2. Glower DD, Christopher TD, Milano CA, et al. Performance status and outcome after coronary artery bypass grafting in persons aged 80 to 93 years. Am J Cardiol 1992;70:567–71. 3. Cane ME, Chen C, Bailey BM, et al. CABG in octogenarians: early and late events and actuarial survival in comparison with a matched population. Ann Thorac Surg 1995;60:1033–7. 4. Alexander KP, Peterson ED. Coronary artery bypass grafting in the elderly. Am Heart J 1997;134:856 – 64. 5. Graham MM, Ghali WA, Faris PD, et al. Survival after coronary revascularization in the elderly. Circulation 2002;105:2378 – 84. 6. The TIME Investigators. Trial of invasive versus medical therapy in elderly patients with chronic symptomatic coronary-artery disease (TIME): a randomized trial. Lancet 2001;358:951–7. 7. Pfisterer M, Buser P, Osswald S, et al. Outcome of elderly patients with chronic symptomatic coronary artery disease with an invasive versus optimized medical treatment strategy: one-year results of the randomized TIME trial. JAMA 2003;289:1117–23. 8. Patel NC, Deodhar AP, Grayson AD, et al. Neurological outcomes in coronary surgery: independent effect of avoiding cardiopulmonary bypass. Ann Thorac Surg 2002;74:400 – 6 . 9. Alexander KP, Harding T, Coombs L, et al. Are patients properly informed prior to revascularization decisions? ACC oral presentation; 2003.