Assessing the impact of frailty on outcomes of cardiac surgery

Extensive research into the impact of frailty on the outcomes of cardiac surgery has been undertaken by Dr. Jonathan Afilalo, a JGH cardiologist who sees many elderly patients and has particular concern for frail individuals who suffer from heart disease.

Dr. Afilalo is also trying to determine how best to measure frailty, so that the best treatment plan can be developed for his patients. This is a critical requirement, since an accurate assessment of frailty can serve as a strong prognostic tool to demonstrate whether a patient is likely to experience a positive recovery from surgery.

To this end, Dr. Afilalo looked at seven frailty scales to predict how elderly patients will recover from two cardiac surgical procedures, transcatheter aortic valve replacement and surgical aortic valve replacement. A clinical study of more than 1,000 patients with a median age of 82—undertaken at 14 centres and led at the JGH—revealed that frailty is a major risk factor for death and disability after both surgical procedures.

“Because there is no clear consensus among clinicians on how to objectively evaluate frailty, we compared different measures of frailty,” Dr. Afilalo explains. “The scale that we developed, called the Essential Frailty Toolset, proved to be the strongest predictor of outcomes.”

The Toolset consists of a four-item scale that measures lower-extremity weakness, cognitive impairment, amenia (hemoglobin) and serum albumin.

“We use these measures to help us tailor therapy for the individual patient to enhance their recovery after the acute procedure and their quality of life one or two years afterward,” Dr. Afilalo says.

“The vast majority of patients survive the actual procedures, but they begin to decline over the ensuing months, largely because of their frailty and deconditioning. Very frail patients may be better suited to less invasive treatment approaches, or they may require more pre- and post-operative rehabilitation and nutritional supplementation.

“The multi-disciplinary approach that we take at the JGH is vital to optimizing patient care. It includes a concerted effort by physiotherapists, nutritionists, geriatricians, cardiologists and cardiac surgeons.”