- Email: [email protected]
or valvular cardiac surgery in patients ≥75 years of age with younger patients
ical chest pain. One year after echocardiography, she underwent coronary artery bypass grafting of the obtuse marginal and left anterior descending coronary arteries. In summary, women with a normal dobutamine stress echocardiographic result have an excellent long-term cardiac prognosis, with a risk of cardiac mortality of 0% and risk of a cardiac event requiring revascularization of only 1% per patient-year. Acknowledgment: We thank Vei-Vei Lee, MS, for help with the statistical analyses.
1. Cohen JL, Greene TO, Ottenweller JE, Binenbaum SZ, Wilchfort SD, Kim CS.
Dobutamine digital echocardiography for detecting coronary artery disease. Am J Cardiol 1991;67:1311–1318. 2. Cohen JL, Ottenweller JE, George AK, Duvvuri S. Comparison of dobutamine and exercise echocardiography for detecting coronary artery disease. Am J Cardiol 1993;72:1226 –1231. 3. Afridi I, Kleiman NS, Raizner AE, Zoghbi WA. Dobutamine echocardiography in myocardial hibernation. Optimal dose and accuracy in predicting recovery of ventricular function after coronary angioplasty. Circulation 1995;91:663– 670. 4. Davila-Roman VG, Waggoner AD, Sicard GA, Geltman EM, Schechtman KB, Perez JE. Dobutamine stress echocardiography predicts surgical outcome in patients with an aortic aneurysm and peripheral vascular disease. J Am Coll Cardiol 1993;21:957–963.
5. Poldermans D, Arnese M, Fioretti PM, Salustri A, Boersma E, Thomson IR, Roelandt JR, van Urk H. Improved cardiac risk stratification in major vascular surgery with dobutamine-atropine stress echocardiography. J Am Coll Cardiol 1995;26:648 – 653. 6. Humphries JO, Kuller L, Ross RS, Friesinger GC, Page EE. Natural history of ischemic heart disease in relation to arteriographic findings: a twelve year study of 224 patients. Circulation 1974;49:489 – 497. 7. Papanicolaou MN, Califf RM, Hlatky MA, McKinnis RA, Harrel FE Jr, Mark DB, McCants B, Rosati RA, Lee KL, Pryor DB. Prognostic implications of angiographically normal and insignificantly narrowed coronary arteries. Am J Cardiol 1986;58:1181–1187. 8. Proudfit WL, Bruschke AVG, Sones FM Jr. Clinical course of patients with normal or slightly or moderately abnormal arteriograms: 10-year follow-up of 521 patients. Circulation 1980;62:712–717. 9. Wackers FJ, Russo DJ, Russo D, Clements JP. Prognostic significance of normal quantitative planar thallium-201 stress scintigraphy in patients with chest pain. J Am Coll Cardiol 1985;6:27–30. 10. Pamelia FX, Gibson RS, Watson DD, Craddock GB, Sirowatka J, Beller GA. Prognosis with chest pain and normal thallium-201 exercise scintigrams. Am J Cardiol 1985;55:920 –926. 11. Steinberg EH, Koss JH, Lee M, Grunwald AM, Bodenheimer MM. Prognostic significance from 10-year follow-up of a qualitatively normal planar exercise thallium test in suspected coronary artery disease. Am J Cardiol 1993; 71:1270 –1273. 12. Steinberg EH, Madmon L, Patel CP, Sedlis SP, Kronzon I, Cohen JL. Long-term prognostic significance of dobutamine echocardiography in patients with suspected coronary artery disease: results of a 5-year follow-up study. J Am Coll Cardiol 1997;29:969 –973. 13. Yeleti R, Feinberg N, Segar DS, Feigenbaum H, Sawada SG. Long-term prognosis of patients with normal dobutamine stress echocardiogram studies (abstr). JASE 1997;10:445. 14. Anderson RN, Kochanek KD, Murphy SL. Report of final mortality statistics, 1995. Monthly Vital Stat Rep 1995;45(suppl 2):23–33.
Comparison of Quality of Life After Coronary and/or Valvular Cardiac Surgery in Patients >75 Years of Age With Younger Patients Jan A. Heijmeriks,
MD,
Salima Pourrier, MS, Pim Dassen, Hein J.J. Wellens, MD
ontemporary studies have indicated that open heart surgery in elderly patients can be performed C with a low mortality rate. However, only limited 1–5
information is available about the quality of life after different types of open heart surgery in elderly patients compared with younger patients. The effect of cardiac surgery on quality of life was studied prospectively in 200 elderly patients aged $75 years and 400 younger patients. •••
From September 1993 to December 1996, we studied 200 patients $75 years (mean age 78, range 75 to 91) who underwent open heart surgery. Each of these patients was matched with 2 patients ,75 years old (mean age 65, range 35 to 74), who underwent same procedure and were the same sex (Table I). Sixty-six percent had coronary surgery; the remaining patients had valvular surgery (18%), or combined coronary and valvular surgery (16%). Fifty-four percent of the patients were women. The median follow-up duration From the Departments of Cardiology and Cardiothoracic Surgery, Academic Hospital, Maastricht, The Netherlands. Dr. Heijmeriks’ address is: Vivaldi 34, 2681 KN Monster, The Netherlands. E-mail: [email protected]. Manuscript received October 1, 1998; revised manuscript received and accepted November 24,1998. ©1999 by Excerpta Medica, Inc. All rights reserved.
PhD,
Kees Prenger,
MD,
and
of the surviving patients was 31 months (range 12 to 52). To evaluate quality of life, 2 tests were selected. These tests have a limited number of questions that were easy to respond to in a short time by the patient and covered various aspects, such as mood, social functioning, and physical condition. The first test is the Hospital Anxiety and Depression (HAD) scale (Snaith6 and Zigmund and Snaith,7 of which an official Dutch translation is available). This questionnaire has 14 multiple choice questions dealing with anxiety and depressive complaints, with a range from 0 to 21. A higher number represents a worse score for that item. The second test is the Nottingham Health Profile (NHP) (Hunt et al8 and Jenkinson et al,9 of which a Dutch translation has been available since 1993). The first part of this questionnaire has 6 main items, consisting of energy, pain, emotional reactions, sleep, social isolation, and physical mobility, with a total of 38 questions that can be answered by filling out “yes”or “no.” The range for this scale is from 0 to 100. In this test also, a higher number represents a worse score for that item. Part 2 of the NHP has 7 questions about daily activity limitations (work, housekeeping, social contacts in/outside home, sexual activity, hobbies, and recreational activities). These items were put 0002-9149/99/$–see front matter PII S0002-9149(99)00028-4
1129
TABLE I Type of Surgery in Patients Studied Age Group
CABG Valvular surgery CABG 1 valvular surgery Total
Young
Old
n (%)
n (%)
262 72 66 400
(65.5%) (18.0%) (16.5%) (100%)
131 36 33 200
(65.5%) (18.0%) (16.5%) (100%)
CABG 5 coronary artery bypass grafting.
FIGURE 1. Hospital Anxiety and Depression (H.A.D.) scale.
FIGURE 2. General well-being at the end of the follow-up period (range 12 to 52 months) in comparison with preoperative situation.
together into a sum score (range 0 to 7), in which a higher score represents a higher limitation of social activities. Both questionnaires were filled out by the patient 1 day before surgery, 2 months after surgery, and 6 1130 THE AMERICAN JOURNAL OF CARDIOLOGYT
VOL. 83
months after surgery. The time needed to fill out these questionnaires varied between 5 and 15 minutes. Several studies showed that these questionnaires are suitable for serial comparison and useful in showing changes of quality of life after surgery. Validation studies were also performed of the Dutch version of these questionnaires.10,11 At the end of the follow-up period (median 31 months), 161 younger patients and 83 older patients randomly selected from the study population were asked by telephone for their subjective opinion about the final surgical outcome. These results were graded into 3 categories: (1) patients who felt better compared with before the operation, (2) patients who were without change in well-being, and (3) patients who experienced permanent worsening after the operation. Elderly patients ($75 years) referred for coronary surgery more often had 3-vessel disease (81.7 vs 66.3%), a higher incidence of severe left main stenosis (13.7 vs 7.7%), and more often reported angina at rest (69 vs 56%). The incidence of hypercholesterolemia (24.7 vs 37.9%; p 5 0.002) and smoking (13.8 vs 24%; p 5 0.001) was clearly lower in the elderly patients. This might explain why the onset of coronary insufficiency is at a more advanced age. No differences were seen in renal function, left ventricular ejection fraction, and pulmonary function. In elderly patients referred for valvular surgery, a higher incidence of diabetes mellitus (15.9 vs 12.3%) and a lower incidence of treated hypertension (20.3 vs 33.3%) were found. Elderly patients had a higher incidence of emergency surgery (53.0 vs 43.5%; p ,0.05), which was defined as surgery during the same hospital admission as the cardiac catheterization. The unpaired t test was used to demonstrate differences in interval variables between both age groups. For nominal variables, chi-square analysis of contingency was used. In case of ordinal variables, the Mann-Whitney rank-sum test was performed. To demonstrate changes in each treatment group after surgery, the paired t test was used for interval variables, McNemar’s test for nominal variables, and the Wilcoxon signed-rank test for ordinal variables. A p value ,0.05 was considered statistically significant. Analyses were conducted using SPSS for Windows, release 7.5 (SPSS Inc., Chicago, Illinois). Hospital mortality (defined as mortality within 30 days after surgery) occurred in 22 patients (5.5%) in the younger group and in 9 patients (4.5%) in the older group (p 5 NS). The 1-year mortality (including hospital mortality) included 32 patients (8.0%) in the younger group and 15 patients (7.5%) in the older group (p 5 NS). The quality-of-life questionnaires were filled out 2 and 6 months after surgery by 352 of 373 surviving younger patients (94.3%) and 170 of 188 surviving older patients (90.4%). Both groups showed a significant improvement of anxiety and depression scores 2 months after surgery. No significant changes were seen between 2 and 6 months after surgery (Figure 1). Patients who had preoperative signs of depression (HAD score $12; n 5 44) had the same 1-year APRIL 1, 1999
TABLE II Hospital Anxiety and Depression Scale and Nottingham Health Profile Young Preoperative Anxiety* Depression* Energy* Emotional reactions† Pain† Sleep† Social isolation† Physical mobility† Daily activities†
8.24 6.44 48.5 29.1 23.2 43.4 10.5 30.8 2.81
6 6 6 6 6 6 6 6 6
4.45 3.99 40.4 25.8 24.8 33.7 19.5 27.1 1.9
Old
2 mo 5.44 5.07 24.4 15.1 14.9 35.2 6.54 17.2 1.71
6 6 6 6 6 6 6 6 6
6 mo \
4.28 4.39\ 33.9\ 21.9\ 23.2\ 34.8\ 15.3§ 22.7\ 1.89\
5.91 5.26 24.8 16.9 12.8 32.3 8.91 16.6 1.53
6 6 6 6 6 6 6 6 6
Preoperative \
4.61 4.54\ 34.5\ 23.1\ 20.5\ 33.8\ 19.3 23.3\ 1.85\
7.65 6.63 44.3 27.4 22.8 44.8 11.0 35.9 2.40
6 6 6 6 6 6 6 6 6
4.40 4.41 39.1 25.9 23.2 35.8 17.6 26.6 1.8
2 mo 4.88 5.37 27.9 15.7 12.3 33.5 8.70 23.9 1.59
6 6 6 6 6 6 6 6 6
6 mo \
3.73 4.45§ 34.0\ 22.2\ 20.4\ 35.6\ 17.6 24.2\ 1.7\
5.15 5.19 26.2 16.6 16.2 33.3 6.67 25.0 1.42
6 6 6 6 6 6 6 6 6
4.13\ 4.36§ 35.0\ 22.7\ 23.0§ 37.3\ 15.5§ 25.0\ 1.76\
All values are given as mean 6 SD. *Hospital Anxiety and Depression scale. † Nottingham Health Profile. p Values represent differences compared with preoperative values. ‡p ,0.05; §p ,0.01; \p ,0.001.
mortality (6.9%) in both age groups as patients without depression (7.9%; p 5 NS). However, general well-being at a median follow-up of 32 months was less if signs of preoperative depression were present, especially in the older group (Figure 2). There were no significant differences in New York Heart Association functional class 6 months after surgery between depressed (76% improvement) and nondepressed patients (81% improvement). All items of the NHP, except social isolation, showed a clear improvement in the 2 months after surgery, again with no significant changes in the period between 2 and 6 months after surgery (Table II). Symptoms of social isolation before surgery were very mild in both age groups. This may explain why there are only minimal changes for that variable after surgery. Both groups showed a similar improvement of daily activities 2 months after surgery, as measured in part 2 of the NHP, which improved further 6 months after surgery. Younger patients had preoperatively more limitations in social activities, because elderly patients usually had retired from working. Questioning by telephone at the end of the follow-up period (median 31 months, range 12 to 52) revealed a clear improvement of general well-being in 73.3% of younger and 69.9% of older patients. This includes depressed and nondepressed patients. No differences in well-being compared with before the operation were present in 13.7% of younger and 15.7% of older patients, and a worsening of general wellbeing after surgery was present in 13.0% of younger and 14.5% of older patients (p 5 NS). Preoperatively, more elderly people had angina at rest compared with younger patients (50.5 vs 41%; p ,0.05). Six and 12 months after surgery, all patients were asked again about anginal and dyspnea complaints. Compared with preoperative values, there was a clear improvement of complaints in both groups (p ,0.001), without any differences between the age groups. Between 6 and 12 months after surgery, there was a moderate increase in anginal complaints (p ,0.01), and to a lesser extent, complaints of dyspnea (p ,0.05) in both age groups (Figure 3).
FIGURE 3. Changes in complaints of angina and dyspnea after surgery in both age groups.
•••
In our study we found that, although elderly patients had more severe coronary artery disease and more often required emergency surgery, their surgical and 1-year mortality were identical to that of younger patients. Both quality-of-life questionnaires showed improvement in nearly all aspects of quality of life in both age groups. Relief of anginal and dyspnea complaints were similar in both groups. Several studies have shown that there is an improvement of quality of life in elderly patients.1,12–16 Our study indicates that this improvement is independent of patient age. Some studies suggest that preoperative signs of depression predict a worse outcome after cardiac surgery.17–19 We found that the mortality and New York Heart Association functional class were identical in depressed and nondepressed patients. However, the subjective signs of general well-being were worse in elderly depressed patients. In conclusion, there is a definite improvement in quality of life after cardiac surgery, which is independent of patient age. BRIEF REPORTS
1131
1. Chocron S, Rude N, Dussaucy A, Leplege A, Clement F, Alwan K, Viel JF, Etievent JP. Quality of life after open-heart surgery in patients over 75 years old. Age Ageing 1996;25:8 –11. 2. Deiwick M, Mo¨llhoff T, Budde T, Scheld HH. Cardiac surgery in patients aged 80 years and above: does outcome justify significant perioperative morbidity? Cardiol Elderly 1995;3:381–386. 3. Katz NM, Hannan RL, Hopkins RA, Wallace RB. Cardiac operations in patients aged 70 years and over: mortality, length of stay, and hospital charge. Ann Thorac Surg 1995;60:96 –100. 4. Shah VZ, Rosenfeldt FL, Parkin GW, Ugoni AM, Habersberger PG, Cooper E. Cardiac surgery in the very elderly. Med J Aust 1994;160:332–334. 5. Subayi JB, de Brux JL, Delhumeau A, Lotfi N, Moreau X, Cottineau C, Bukowski JG, Corbeau JJ, Pillet J. Chirurgie cardiaque chez les patients ages; resultats immediats et a moyen terme chez 100 patients ages de 75 ans et plus. [Cardiac surgery in aged patients; immediate and medium-term results in 100 patients over 75 years of age] Arch Mal Coeur Vaiss 1994;87:1671–1677. 6. Snaith P. Measuring anxiety and depression. Practitioner 1993;237:554 –559. 7. Zigmund AS, Snaith RP. The hospital anxiety and depression scale. Acta Psychiatr Scand 1983;67:361–370. 8. Hunt SM, McKenna SP, McEwen J, Williams J, Papp E. The Nottingham health profile: subjective health status and medical consultations. Soc Sci Med 1981;15A:221–229. 9. Jenkinson C, Fitzpatrick R, Argyle M. The Nottingham health profile: an analysis of its sensitivity in differentiating illness groups. Soc Sci Med 1988;27:1411–1414. 10. Spinhoven P, Ormel J, Sloekers PP, Kempen GI, Speckens AE, Van Hemert AM. A validation study of the Hospital Anxiety and Depression Scale (HADS) in different groups of Dutch subjects. Psychol Med 1997;27:363–370.
11. Erdman RA, Passchier J, Kooijman M, Stronks DL. The Dutch version of the Nottingham Health Profile: investigations of psychometric aspects. Psychol Rep 1993;72:1027–1035. 12. Bunzel B, Eckersberger F. Changes in life quality after aortocoronary bypass and valve replacement: a subjective criterion for assessing operative results. Thorac Cardiovasc Surg 1987;35:242–247. 13. Caine N, Harrison SC, Sharples LD, Wallwork J. Prospective study of quality of life before and after coronary artery bypass grafting. BMJ 1991; 302:511–516. 14. Chocron S, Etievent JP, Viel JF, Dussaucy A, Clement F, Alwan K, Neidhardt M, Schipman N. Prospective study of quality of life before and after open heart operations. Ann Thorac Surg 1996;61:153–157. 15. Kumar P, Zehr KJ, Chang A, Cameron DE, Baumgartner WA. Quality of life in octogenarians after open heart surgery. Chest 1995;108:919 –926. 16. Olsson M, Janfjall H, Orth-Gomer K, Unden A, Rosenqvist M. Quality of life in octogenarians after valve replacement due to aortic stenosis. A prospective comparison with younger patients. Eur Heart J 1996;17:583–589. 17. Oxman TE, Freeman DH Jr, Manheimer ED. Lack of social participation or religious strength and comfort as risk factors for death after cardiac surgery in the elderly. Psychosom Med 1995;57:5–15. 18. Lorna Cay E, O’Rourke A. The emotional state of patients after coronary bypass surgery. In: Walter PJ, ed: Quality of Life after Open Heart Surgery. Dordrecht, The Netherlands: Kluwer Academic Publishers, 1992:177–183. 19. Duits AA, Boeke S, Taams MA, Passchier J, Erdman RA. Prediction of quality of life after coronary artery bypass graft surgery: a review and evaluation of multiple, recent studies. Psychosom Med 1997;59:257–268.
Effect of Hormone Replacement Therapy on Left Ventricular Hypertrophy Wen Kwang Lim, MBBS, Barry Wren, MD, MBBS, MHPeD, Nigel Jepson, Shiva Roy, MBBS, and Gideon Caplan, MBBS here is strong evidence indicating that postmenopausal hormone replacement therapy reduces the T risk of coronary artery disease as well as mortality from cardiovascular diseases.1 A review of 31 observational studies related to postmenopausal hormone replacement therapy showed that there was a 44% reduction in the risk of coronary heart disease.2 The mechanisms by which estrogen exerts this protective effect have not been fully elucidated. It is known that estrogen replacement therapy in postmenopausal women reduces low-density lipoprotein cholesterol and increases high-density lipoprotein cholesterol by 10% to 15%.3 There also may be some effect on endothelial function; however, this explains only 35% to 50% of the cardioprotective role of estrogen.4 We examined the effects of long-term hormone replacement therapy on left ventricular (LV) wall thickness in women. •••
A case control study was performed comparing 20 women who had been receiving hormone replacement therapy for .10 years with 19 healthy controls. All subjects were Caucasian, postmenopausal, and were .63 years of age. Subjects who had a past history of hypertension or cardiac disease or who were taking From the Departments of Geriatrics and Cardiology, Prince of Wales Hospital, and the Menopause Centre, Royal Hospital for Women, University of New South Wales, Sydney, Australia. Dr. Lim’s address is: 3/125 Walpole Street, Kew, Victoria 3101, Australia. Manuscript received September 18, 1998; revised manuscript received and accepted December 3, 1998.
1132
©1999 by Excerpta Medica, Inc. All rights reserved.
MBBS,
cardiac medications were excluded from the study. Subjects also were excluded from the study if they had a systolic blood pressure .140 mm Hg and/or diastolic blood pressure .90 mm Hg after 3 readings. The study group was selected from a menopause clinic. Of 110 patients who had been receiving hormone replacement therapy for .10 years, 36 women volunteered for the study. Twenty-two women fulfilled the criteria and were enlisted. Two were excluded: 1 had suboptimal images on echocardiography, and the other was found to be taking flecainide and enalapril on presentation. The control group consisted of 21 women obtained from various volunteer organizations, who were independent community-dwelling persons. The subjects were matched for age with the study group. Two subjects were excluded: 1 because of previously undiagnosed hypertension, and the other because of marked LV hypertrophy and subsequently found to be taking furosemide and amiloride for peripheral edema. Assessment of subjects included a medical and obstetric history. Subjects also were asked about alcohol consumption, smoking, and physical activity. Alcohol consumption was coded into 4 groups: 0 5 no alcohol, 1 5 0 to 20 g/day, 2 5 21 to 40 g/day, and 3 5 .40 g/day. Exercise was categorized as follows: 0 5 house bound, 1 5 leaves house most days but no regular exercise, 2 5 regular exercise #3 times/week, and 3 5 regular exercise .3 times/week. Regular exercise was defined as categories 2 and 3. Examination included height, weight, and blood pressure. Three blood pressure readings were taken at 0002-9149/99/$–see front matter PII S0002-9149(99)00029-6
1. Cohen JL, Greene TO, Ottenweller JE, Binenbaum SZ, Wilchfort SD, Kim CS.
Dobutamine digital echocardiography for detecting coronary artery disease. Am J Cardiol 1991;67:1311–1318. 2. Cohen JL, Ottenweller JE, George AK, Duvvuri S. Comparison of dobutamine and exercise echocardiography for detecting coronary artery disease. Am J Cardiol 1993;72:1226 –1231. 3. Afridi I, Kleiman NS, Raizner AE, Zoghbi WA. Dobutamine echocardiography in myocardial hibernation. Optimal dose and accuracy in predicting recovery of ventricular function after coronary angioplasty. Circulation 1995;91:663– 670. 4. Davila-Roman VG, Waggoner AD, Sicard GA, Geltman EM, Schechtman KB, Perez JE. Dobutamine stress echocardiography predicts surgical outcome in patients with an aortic aneurysm and peripheral vascular disease. J Am Coll Cardiol 1993;21:957–963.
5. Poldermans D, Arnese M, Fioretti PM, Salustri A, Boersma E, Thomson IR, Roelandt JR, van Urk H. Improved cardiac risk stratification in major vascular surgery with dobutamine-atropine stress echocardiography. J Am Coll Cardiol 1995;26:648 – 653. 6. Humphries JO, Kuller L, Ross RS, Friesinger GC, Page EE. Natural history of ischemic heart disease in relation to arteriographic findings: a twelve year study of 224 patients. Circulation 1974;49:489 – 497. 7. Papanicolaou MN, Califf RM, Hlatky MA, McKinnis RA, Harrel FE Jr, Mark DB, McCants B, Rosati RA, Lee KL, Pryor DB. Prognostic implications of angiographically normal and insignificantly narrowed coronary arteries. Am J Cardiol 1986;58:1181–1187. 8. Proudfit WL, Bruschke AVG, Sones FM Jr. Clinical course of patients with normal or slightly or moderately abnormal arteriograms: 10-year follow-up of 521 patients. Circulation 1980;62:712–717. 9. Wackers FJ, Russo DJ, Russo D, Clements JP. Prognostic significance of normal quantitative planar thallium-201 stress scintigraphy in patients with chest pain. J Am Coll Cardiol 1985;6:27–30. 10. Pamelia FX, Gibson RS, Watson DD, Craddock GB, Sirowatka J, Beller GA. Prognosis with chest pain and normal thallium-201 exercise scintigrams. Am J Cardiol 1985;55:920 –926. 11. Steinberg EH, Koss JH, Lee M, Grunwald AM, Bodenheimer MM. Prognostic significance from 10-year follow-up of a qualitatively normal planar exercise thallium test in suspected coronary artery disease. Am J Cardiol 1993; 71:1270 –1273. 12. Steinberg EH, Madmon L, Patel CP, Sedlis SP, Kronzon I, Cohen JL. Long-term prognostic significance of dobutamine echocardiography in patients with suspected coronary artery disease: results of a 5-year follow-up study. J Am Coll Cardiol 1997;29:969 –973. 13. Yeleti R, Feinberg N, Segar DS, Feigenbaum H, Sawada SG. Long-term prognosis of patients with normal dobutamine stress echocardiogram studies (abstr). JASE 1997;10:445. 14. Anderson RN, Kochanek KD, Murphy SL. Report of final mortality statistics, 1995. Monthly Vital Stat Rep 1995;45(suppl 2):23–33.
Comparison of Quality of Life After Coronary and/or Valvular Cardiac Surgery in Patients >75 Years of Age With Younger Patients Jan A. Heijmeriks,
MD,
Salima Pourrier, MS, Pim Dassen, Hein J.J. Wellens, MD
ontemporary studies have indicated that open heart surgery in elderly patients can be performed C with a low mortality rate. However, only limited 1–5
information is available about the quality of life after different types of open heart surgery in elderly patients compared with younger patients. The effect of cardiac surgery on quality of life was studied prospectively in 200 elderly patients aged $75 years and 400 younger patients. •••
From September 1993 to December 1996, we studied 200 patients $75 years (mean age 78, range 75 to 91) who underwent open heart surgery. Each of these patients was matched with 2 patients ,75 years old (mean age 65, range 35 to 74), who underwent same procedure and were the same sex (Table I). Sixty-six percent had coronary surgery; the remaining patients had valvular surgery (18%), or combined coronary and valvular surgery (16%). Fifty-four percent of the patients were women. The median follow-up duration From the Departments of Cardiology and Cardiothoracic Surgery, Academic Hospital, Maastricht, The Netherlands. Dr. Heijmeriks’ address is: Vivaldi 34, 2681 KN Monster, The Netherlands. E-mail: [email protected]. Manuscript received October 1, 1998; revised manuscript received and accepted November 24,1998. ©1999 by Excerpta Medica, Inc. All rights reserved.
PhD,
Kees Prenger,
MD,
and
of the surviving patients was 31 months (range 12 to 52). To evaluate quality of life, 2 tests were selected. These tests have a limited number of questions that were easy to respond to in a short time by the patient and covered various aspects, such as mood, social functioning, and physical condition. The first test is the Hospital Anxiety and Depression (HAD) scale (Snaith6 and Zigmund and Snaith,7 of which an official Dutch translation is available). This questionnaire has 14 multiple choice questions dealing with anxiety and depressive complaints, with a range from 0 to 21. A higher number represents a worse score for that item. The second test is the Nottingham Health Profile (NHP) (Hunt et al8 and Jenkinson et al,9 of which a Dutch translation has been available since 1993). The first part of this questionnaire has 6 main items, consisting of energy, pain, emotional reactions, sleep, social isolation, and physical mobility, with a total of 38 questions that can be answered by filling out “yes”or “no.” The range for this scale is from 0 to 100. In this test also, a higher number represents a worse score for that item. Part 2 of the NHP has 7 questions about daily activity limitations (work, housekeeping, social contacts in/outside home, sexual activity, hobbies, and recreational activities). These items were put 0002-9149/99/$–see front matter PII S0002-9149(99)00028-4
1129
TABLE I Type of Surgery in Patients Studied Age Group
CABG Valvular surgery CABG 1 valvular surgery Total
Young
Old
n (%)
n (%)
262 72 66 400
(65.5%) (18.0%) (16.5%) (100%)
131 36 33 200
(65.5%) (18.0%) (16.5%) (100%)
CABG 5 coronary artery bypass grafting.
FIGURE 1. Hospital Anxiety and Depression (H.A.D.) scale.
FIGURE 2. General well-being at the end of the follow-up period (range 12 to 52 months) in comparison with preoperative situation.
together into a sum score (range 0 to 7), in which a higher score represents a higher limitation of social activities. Both questionnaires were filled out by the patient 1 day before surgery, 2 months after surgery, and 6 1130 THE AMERICAN JOURNAL OF CARDIOLOGYT
VOL. 83
months after surgery. The time needed to fill out these questionnaires varied between 5 and 15 minutes. Several studies showed that these questionnaires are suitable for serial comparison and useful in showing changes of quality of life after surgery. Validation studies were also performed of the Dutch version of these questionnaires.10,11 At the end of the follow-up period (median 31 months), 161 younger patients and 83 older patients randomly selected from the study population were asked by telephone for their subjective opinion about the final surgical outcome. These results were graded into 3 categories: (1) patients who felt better compared with before the operation, (2) patients who were without change in well-being, and (3) patients who experienced permanent worsening after the operation. Elderly patients ($75 years) referred for coronary surgery more often had 3-vessel disease (81.7 vs 66.3%), a higher incidence of severe left main stenosis (13.7 vs 7.7%), and more often reported angina at rest (69 vs 56%). The incidence of hypercholesterolemia (24.7 vs 37.9%; p 5 0.002) and smoking (13.8 vs 24%; p 5 0.001) was clearly lower in the elderly patients. This might explain why the onset of coronary insufficiency is at a more advanced age. No differences were seen in renal function, left ventricular ejection fraction, and pulmonary function. In elderly patients referred for valvular surgery, a higher incidence of diabetes mellitus (15.9 vs 12.3%) and a lower incidence of treated hypertension (20.3 vs 33.3%) were found. Elderly patients had a higher incidence of emergency surgery (53.0 vs 43.5%; p ,0.05), which was defined as surgery during the same hospital admission as the cardiac catheterization. The unpaired t test was used to demonstrate differences in interval variables between both age groups. For nominal variables, chi-square analysis of contingency was used. In case of ordinal variables, the Mann-Whitney rank-sum test was performed. To demonstrate changes in each treatment group after surgery, the paired t test was used for interval variables, McNemar’s test for nominal variables, and the Wilcoxon signed-rank test for ordinal variables. A p value ,0.05 was considered statistically significant. Analyses were conducted using SPSS for Windows, release 7.5 (SPSS Inc., Chicago, Illinois). Hospital mortality (defined as mortality within 30 days after surgery) occurred in 22 patients (5.5%) in the younger group and in 9 patients (4.5%) in the older group (p 5 NS). The 1-year mortality (including hospital mortality) included 32 patients (8.0%) in the younger group and 15 patients (7.5%) in the older group (p 5 NS). The quality-of-life questionnaires were filled out 2 and 6 months after surgery by 352 of 373 surviving younger patients (94.3%) and 170 of 188 surviving older patients (90.4%). Both groups showed a significant improvement of anxiety and depression scores 2 months after surgery. No significant changes were seen between 2 and 6 months after surgery (Figure 1). Patients who had preoperative signs of depression (HAD score $12; n 5 44) had the same 1-year APRIL 1, 1999
TABLE II Hospital Anxiety and Depression Scale and Nottingham Health Profile Young Preoperative Anxiety* Depression* Energy* Emotional reactions† Pain† Sleep† Social isolation† Physical mobility† Daily activities†
8.24 6.44 48.5 29.1 23.2 43.4 10.5 30.8 2.81
6 6 6 6 6 6 6 6 6
4.45 3.99 40.4 25.8 24.8 33.7 19.5 27.1 1.9
Old
2 mo 5.44 5.07 24.4 15.1 14.9 35.2 6.54 17.2 1.71
6 6 6 6 6 6 6 6 6
6 mo \
4.28 4.39\ 33.9\ 21.9\ 23.2\ 34.8\ 15.3§ 22.7\ 1.89\
5.91 5.26 24.8 16.9 12.8 32.3 8.91 16.6 1.53
6 6 6 6 6 6 6 6 6
Preoperative \
4.61 4.54\ 34.5\ 23.1\ 20.5\ 33.8\ 19.3 23.3\ 1.85\
7.65 6.63 44.3 27.4 22.8 44.8 11.0 35.9 2.40
6 6 6 6 6 6 6 6 6
4.40 4.41 39.1 25.9 23.2 35.8 17.6 26.6 1.8
2 mo 4.88 5.37 27.9 15.7 12.3 33.5 8.70 23.9 1.59
6 6 6 6 6 6 6 6 6
6 mo \
3.73 4.45§ 34.0\ 22.2\ 20.4\ 35.6\ 17.6 24.2\ 1.7\
5.15 5.19 26.2 16.6 16.2 33.3 6.67 25.0 1.42
6 6 6 6 6 6 6 6 6
4.13\ 4.36§ 35.0\ 22.7\ 23.0§ 37.3\ 15.5§ 25.0\ 1.76\
All values are given as mean 6 SD. *Hospital Anxiety and Depression scale. † Nottingham Health Profile. p Values represent differences compared with preoperative values. ‡p ,0.05; §p ,0.01; \p ,0.001.
mortality (6.9%) in both age groups as patients without depression (7.9%; p 5 NS). However, general well-being at a median follow-up of 32 months was less if signs of preoperative depression were present, especially in the older group (Figure 2). There were no significant differences in New York Heart Association functional class 6 months after surgery between depressed (76% improvement) and nondepressed patients (81% improvement). All items of the NHP, except social isolation, showed a clear improvement in the 2 months after surgery, again with no significant changes in the period between 2 and 6 months after surgery (Table II). Symptoms of social isolation before surgery were very mild in both age groups. This may explain why there are only minimal changes for that variable after surgery. Both groups showed a similar improvement of daily activities 2 months after surgery, as measured in part 2 of the NHP, which improved further 6 months after surgery. Younger patients had preoperatively more limitations in social activities, because elderly patients usually had retired from working. Questioning by telephone at the end of the follow-up period (median 31 months, range 12 to 52) revealed a clear improvement of general well-being in 73.3% of younger and 69.9% of older patients. This includes depressed and nondepressed patients. No differences in well-being compared with before the operation were present in 13.7% of younger and 15.7% of older patients, and a worsening of general wellbeing after surgery was present in 13.0% of younger and 14.5% of older patients (p 5 NS). Preoperatively, more elderly people had angina at rest compared with younger patients (50.5 vs 41%; p ,0.05). Six and 12 months after surgery, all patients were asked again about anginal and dyspnea complaints. Compared with preoperative values, there was a clear improvement of complaints in both groups (p ,0.001), without any differences between the age groups. Between 6 and 12 months after surgery, there was a moderate increase in anginal complaints (p ,0.01), and to a lesser extent, complaints of dyspnea (p ,0.05) in both age groups (Figure 3).
FIGURE 3. Changes in complaints of angina and dyspnea after surgery in both age groups.
•••
In our study we found that, although elderly patients had more severe coronary artery disease and more often required emergency surgery, their surgical and 1-year mortality were identical to that of younger patients. Both quality-of-life questionnaires showed improvement in nearly all aspects of quality of life in both age groups. Relief of anginal and dyspnea complaints were similar in both groups. Several studies have shown that there is an improvement of quality of life in elderly patients.1,12–16 Our study indicates that this improvement is independent of patient age. Some studies suggest that preoperative signs of depression predict a worse outcome after cardiac surgery.17–19 We found that the mortality and New York Heart Association functional class were identical in depressed and nondepressed patients. However, the subjective signs of general well-being were worse in elderly depressed patients. In conclusion, there is a definite improvement in quality of life after cardiac surgery, which is independent of patient age. BRIEF REPORTS
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1. Chocron S, Rude N, Dussaucy A, Leplege A, Clement F, Alwan K, Viel JF, Etievent JP. Quality of life after open-heart surgery in patients over 75 years old. Age Ageing 1996;25:8 –11. 2. Deiwick M, Mo¨llhoff T, Budde T, Scheld HH. Cardiac surgery in patients aged 80 years and above: does outcome justify significant perioperative morbidity? Cardiol Elderly 1995;3:381–386. 3. Katz NM, Hannan RL, Hopkins RA, Wallace RB. Cardiac operations in patients aged 70 years and over: mortality, length of stay, and hospital charge. Ann Thorac Surg 1995;60:96 –100. 4. Shah VZ, Rosenfeldt FL, Parkin GW, Ugoni AM, Habersberger PG, Cooper E. Cardiac surgery in the very elderly. Med J Aust 1994;160:332–334. 5. Subayi JB, de Brux JL, Delhumeau A, Lotfi N, Moreau X, Cottineau C, Bukowski JG, Corbeau JJ, Pillet J. Chirurgie cardiaque chez les patients ages; resultats immediats et a moyen terme chez 100 patients ages de 75 ans et plus. [Cardiac surgery in aged patients; immediate and medium-term results in 100 patients over 75 years of age] Arch Mal Coeur Vaiss 1994;87:1671–1677. 6. Snaith P. Measuring anxiety and depression. Practitioner 1993;237:554 –559. 7. Zigmund AS, Snaith RP. The hospital anxiety and depression scale. Acta Psychiatr Scand 1983;67:361–370. 8. Hunt SM, McKenna SP, McEwen J, Williams J, Papp E. The Nottingham health profile: subjective health status and medical consultations. Soc Sci Med 1981;15A:221–229. 9. Jenkinson C, Fitzpatrick R, Argyle M. The Nottingham health profile: an analysis of its sensitivity in differentiating illness groups. Soc Sci Med 1988;27:1411–1414. 10. Spinhoven P, Ormel J, Sloekers PP, Kempen GI, Speckens AE, Van Hemert AM. A validation study of the Hospital Anxiety and Depression Scale (HADS) in different groups of Dutch subjects. Psychol Med 1997;27:363–370.
11. Erdman RA, Passchier J, Kooijman M, Stronks DL. The Dutch version of the Nottingham Health Profile: investigations of psychometric aspects. Psychol Rep 1993;72:1027–1035. 12. Bunzel B, Eckersberger F. Changes in life quality after aortocoronary bypass and valve replacement: a subjective criterion for assessing operative results. Thorac Cardiovasc Surg 1987;35:242–247. 13. Caine N, Harrison SC, Sharples LD, Wallwork J. Prospective study of quality of life before and after coronary artery bypass grafting. BMJ 1991; 302:511–516. 14. Chocron S, Etievent JP, Viel JF, Dussaucy A, Clement F, Alwan K, Neidhardt M, Schipman N. Prospective study of quality of life before and after open heart operations. Ann Thorac Surg 1996;61:153–157. 15. Kumar P, Zehr KJ, Chang A, Cameron DE, Baumgartner WA. Quality of life in octogenarians after open heart surgery. Chest 1995;108:919 –926. 16. Olsson M, Janfjall H, Orth-Gomer K, Unden A, Rosenqvist M. Quality of life in octogenarians after valve replacement due to aortic stenosis. A prospective comparison with younger patients. Eur Heart J 1996;17:583–589. 17. Oxman TE, Freeman DH Jr, Manheimer ED. Lack of social participation or religious strength and comfort as risk factors for death after cardiac surgery in the elderly. Psychosom Med 1995;57:5–15. 18. Lorna Cay E, O’Rourke A. The emotional state of patients after coronary bypass surgery. In: Walter PJ, ed: Quality of Life after Open Heart Surgery. Dordrecht, The Netherlands: Kluwer Academic Publishers, 1992:177–183. 19. Duits AA, Boeke S, Taams MA, Passchier J, Erdman RA. Prediction of quality of life after coronary artery bypass graft surgery: a review and evaluation of multiple, recent studies. Psychosom Med 1997;59:257–268.
Effect of Hormone Replacement Therapy on Left Ventricular Hypertrophy Wen Kwang Lim, MBBS, Barry Wren, MD, MBBS, MHPeD, Nigel Jepson, Shiva Roy, MBBS, and Gideon Caplan, MBBS here is strong evidence indicating that postmenopausal hormone replacement therapy reduces the T risk of coronary artery disease as well as mortality from cardiovascular diseases.1 A review of 31 observational studies related to postmenopausal hormone replacement therapy showed that there was a 44% reduction in the risk of coronary heart disease.2 The mechanisms by which estrogen exerts this protective effect have not been fully elucidated. It is known that estrogen replacement therapy in postmenopausal women reduces low-density lipoprotein cholesterol and increases high-density lipoprotein cholesterol by 10% to 15%.3 There also may be some effect on endothelial function; however, this explains only 35% to 50% of the cardioprotective role of estrogen.4 We examined the effects of long-term hormone replacement therapy on left ventricular (LV) wall thickness in women. •••
A case control study was performed comparing 20 women who had been receiving hormone replacement therapy for .10 years with 19 healthy controls. All subjects were Caucasian, postmenopausal, and were .63 years of age. Subjects who had a past history of hypertension or cardiac disease or who were taking From the Departments of Geriatrics and Cardiology, Prince of Wales Hospital, and the Menopause Centre, Royal Hospital for Women, University of New South Wales, Sydney, Australia. Dr. Lim’s address is: 3/125 Walpole Street, Kew, Victoria 3101, Australia. Manuscript received September 18, 1998; revised manuscript received and accepted December 3, 1998.
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©1999 by Excerpta Medica, Inc. All rights reserved.
MBBS,
cardiac medications were excluded from the study. Subjects also were excluded from the study if they had a systolic blood pressure .140 mm Hg and/or diastolic blood pressure .90 mm Hg after 3 readings. The study group was selected from a menopause clinic. Of 110 patients who had been receiving hormone replacement therapy for .10 years, 36 women volunteered for the study. Twenty-two women fulfilled the criteria and were enlisted. Two were excluded: 1 had suboptimal images on echocardiography, and the other was found to be taking flecainide and enalapril on presentation. The control group consisted of 21 women obtained from various volunteer organizations, who were independent community-dwelling persons. The subjects were matched for age with the study group. Two subjects were excluded: 1 because of previously undiagnosed hypertension, and the other because of marked LV hypertrophy and subsequently found to be taking furosemide and amiloride for peripheral edema. Assessment of subjects included a medical and obstetric history. Subjects also were asked about alcohol consumption, smoking, and physical activity. Alcohol consumption was coded into 4 groups: 0 5 no alcohol, 1 5 0 to 20 g/day, 2 5 21 to 40 g/day, and 3 5 .40 g/day. Exercise was categorized as follows: 0 5 house bound, 1 5 leaves house most days but no regular exercise, 2 5 regular exercise #3 times/week, and 3 5 regular exercise .3 times/week. Regular exercise was defined as categories 2 and 3. Examination included height, weight, and blood pressure. Three blood pressure readings were taken at 0002-9149/99/$–see front matter PII S0002-9149(99)00029-6