It's that Frailty Thing Again!

Every year for the past 10 years, the mean age of patients undergoing coronary artery surgery in the UK has gone up . There is a feeling now that we are possibly reaching the biological limits of the bodies that we subject to surgical trauma. Evidence for this perception is the increase in interest in using an index of frailty for pre operative risk assessment. At the recent joint annual meeting of the Society for Cardiothoracic Surgery and the Association of Cardiothoracic Anaesthetists in Manchester UK, a whole session was dedicated to the subject. I have been interested in this subject for a number of years and have posted about it on a number of occasions.

It is therefore not surprising that I feel the need to comment in this paper published recently in Circulation.

In this paper, researchers describe how the addition of various known scores of frailty to existing cardiac surgical risk scores improved the discriminatory power (the area under the curve for the Receiver Operating Characteristic or ROC curve) of the surgical risk score to predict death after a heart operation. Now prediction of early death after surgery is all well and good. What I think is even more important is the ability to predict whether a heart operation can improve the quality of life of these very elderly patients. What's the point of increasing the life years of 86 year old Ethel, who is suffering with critical left main stem stenosis, if she lives them in discomfort from her chest wounds attached to a VAC pump treating her wound infection. The good news is that PROMS or Patient Reported Outcome Measures may help us with the quality of life issue. They have been used routinely in the English NHS to measure quality of life after hip and knee surgery, and varicose vein and hernia surgery . There is now a pilot project looking at PROMS after coronary revascularisation and I get the feeling the findings form these could prove to be very interesting .

Illness Perception in Patient with Heart Valve Disease.

Profiling illness perceptions to identify patients at-risk for decline in health status after heart valve replacement

I read this article recently and although this type of research does not normally do it for me, this paper appealed to me.
I have an interest in the treatment of patients with heart valve disease. I operate on them several times a week and I also supervise a nurse-led postoperative heart valve clinic. The vast majority of patients do very extremely well and derive huge benefit from the type of surgical intervention we provide. There are however some patients who after undergoing certain interventions experience outcomes that can only be described as disappointing, even in the presence of a relatively normal echocardiogram.  I am currently supervising a medical student who very soon will validating a PROMS (patient reported outcome measures) instrument ( a quality of life survey in old currency) for patients with symptomatic heart valve disease. I hope therefore that soon we will have a set of questions that can be used to identify patients who will not do well with surgery. This paper provides important data for that quest of mine.