Influence of Age on Cardiac Surgery Outcomes in United States Veterans
Keywords:veterans, coronary artery bypass, valve surgery, mortality, elderly
Objective: Heart disease is still the leading cause of death for both men and women in the United States, and the rate of cardiovascular disease in veterans is even higher than in civilians. This study examines age-related outcomes for veterans undergoing cardiac surgeries at a single institution.
Methods: We included all veterans undergoing coronary artery bypass grafting (CABG) and/or valve surgery between 1997 to 2017 at a single Veterans Affairs (VA) medical center. We stratified this cohort into 4 age groups: ≤59 years old, 60–69 years old, 70–79 years old, and ≥80 years old.
Outcomes in age groups were compared using standard statistical methods with the ≤59 years old group as reference.
Results: A total of 2,301 patients underwent open cardiac procedures at our institution. The frequency of simultaneous CABG and valve operations increased with age. Usage of cardiopulmonary bypass versus off-pump CABG and operative time was not associated with age. Increased pulmonary and renal complications as well as rates of postoperative arrhythmias all were associated with increasing age. There was no statistically significant difference in 30-day mortality. However, multivariable analysis adjusted for covariates showed all-cause mortality significantly was increased with older age groups (aHR ≥80 years old: 2.94 [2.07-4.17], P < .01; aHR 70-79 years old: 2.15 [1.63-2.83], P < 0.01, with ≤59 years old as reference).
Conclusions: Older patients may have comparable perioperative mortality as their younger counterparts. However, age still is a significant predictor of all-cause mortality, pulmonary and renal complications, and postoperative arrhythmia, and should be considered as a major factor in preoperative risk assessment.
Afilalo J, Steele R, Manning WJ, et al. 2016. Derivation and Validation of Prognosis-Based Age Cutoffs to Define Elderly in Cardiac Surgery. Circ Cardiovasc Qual Outcomes 9:424–431.
Alexander KP, Anstrom KJ, Muhlbaier LH, et al. 2000. Outcomes of cardiac surgery in patients > or = 80 years: results from the National Cardiovascular Network. J Am Coll Cardiol 35:731–738.
Assari S. 2014. Veterans and risk of heart disease in the United States: a cohort with 20 years of follow up. Int J Prev Med 5:703–709.
Bongaarts J. 2009. Human population growth and the demographic transition. Philos Trans R Soc Lond B Biol Sci 364:2985–2990.
Cane ME, Chen C, Bailey BM, et al. 1995. CABG in octogenarians: early and late events and actuarial survival in comparison with a matched population. Ann Thorac Surg 60:1033–1037.
Coelho PNMP, Miranda LMRPC, Barros PMP, et al. 2019. Quality of life after elective cardiac surgery in elderly patients. Interact Cardiovasc Thorac Surg 28:199–205.
Crudeli E, Lazzeri C, Stefano P, et al. 2015. Age as a Prognostic Factor in Patients with Acute Coronary Syndrome undergoing Urgent/Emergency Cardiac Surgery. Heart Lung Circ 24:845–853.
Farquharson SM, Gupta R, Heald RJ, et al. 2001. Surgical decisions in the elderly: the importance of biological age. J R Soc Med 94:232–235.
Friedrich I, Simm A, Kotting J, et al. 2009. Cardiac Surgery in the Elderly Patient. Dtsch Arztebl Int 106:416-22.
Graham MM, Ghali WA, Faris PD, et al. 2002. Survival after coronary revascularization in the elderly. Circulation 105:2378–2384.
Hales CM, Fryar CD, Carroll MD, et al. 2018. Differences in Obesity Prevalence by Demographic Characteristics and Urbanization Level Among Adults in the United States, 2013-2016. JAMA 319:2419–2429.
Hales CM, Fryar CD, Carroll MD, et al. 2018. Trends in Obesity and Severe Obesity Prevalence in US Youth and Adults by Sex and Age, 2007-2008 to 2015-2016. JAMA 319:1723–1725.
Iliodromiti S, Celis-Morales CA, Lyall DM, et al. 2018. The impact of confounding on the associations of different adiposity measures with the incidence of cardiovascular disease: a cohort study of 296,535 adults of white European descent. Eur Heart J 39:1514-1520.
Johnson WM, Smith JM, Woods SE, et al. 2005. Cardiac surgery in octogenarians: does age alone influence outcomes? Arch Surg 140:1089–1093.
Jones R, Nyawo B, Jamieson S, et al. 2011. Current smoking predicts increased operative mortality and morbidity after cardiac surgery in the elderly. Interact Cardiovasc Thorac Surg 12:449–453.
Khan-Kheil AM, Khan HN. 2016. Surgical mortality in patients more than 80 years of age. Ann R Coll Surg Engl 98:177–180.
Krane M, Voss B, Hiebinger A, et al. 2011. Twenty years of cardiac surgery in patients aged 80 years and older: Risks and benefits. Ann Thorac Surg 91:506–513.
Lee DH, Buth KJ, Martin B-J, et al. 2010. Frail patients are at increased risk for mortality and prolonged institutional care after cardiac surgery. Circulation 121:973–978.
Massarweh NN, Kougias P, Wilson MA. 2016. Complications and failure to rescue after inpatient noncardiac surgery in the Veterans Affairs health system. JAMA Surg 151:1157–1165.
Matula SR, Trivedi AN, Miake-Lye I, et al. 2010. Comparisons of quality of surgical care between the US Department of Veterans affairs and the private sector. J Am Coll Surg 211:823-832.
McNeely C, Markwell S, Vassileva C. 2016. Trends in Patient Characteristics and Outcomes of Coronary Artery Bypass Grafting in the 2000 to 2012 Medicare Population. Ann Thorac Surg 102:132–138.
Nashef SAM, Roques F, Sharples LD, et al. 2012. Euroscore II. Eur J Cardiothorac Surg 41:734–745.
Ngaage DL, Britchford G, Cale ARJ. 2011. The influence of an ageing population on care and clinical resource utilisation in cardiac surgery. Br J Cardiol 18:28-32.
O'Brien SM, Shahian DM, Filardo G, et al. 2009. The Society of Thoracic Surgeons 2008 Cardiac Surgery Risk Models: Part 2-Isolated Valve Surgery. Ann Thorac Surg 88:S23-42.
Pemberton M, Reid A, London NJ, et al. 1998. Carotid endarterectomy is safe in selected elderly patients. Br J Surg 85:507.
Peterson ED, Cowper PA, Jollis JG, et al. 1995. Outcomes of coronary artery bypass graft surgery in 24,461 patients aged 80 years or older. Circulation 92:II85-91.
Poullis M, Pullan M, Chalmers J, et al. 2015. The validity of the original EuroSCORE and EuroSCORE II in patients over the age of seventy. Interact Cardiovasc Thorac Surg 20:172–177.
Ranucci M, Castelvecchio S, Menicanti L, et al. 2010. Accuracy, calibration and clinical performance of the EuroSCORE: can we reduce the number of variables? Eur J Cardiothorac Surg 37:724–729.
Rosenthal GE, Sarrazin MV, Hannan EL, et al. 2003. In-hospital mortality following coronary artery bypass graft surgery in Veterans Health Administration and private sector hospitals. Med Care 41:522-535.
Rowe R, Iqbal J, Murali-Krishnan R, et al. 2014. Role of frailty assessment in patients undergoing cardiac interventions. Open Heart 1:e000033.
Saxena A, Shan L, Reid C, et al. 2013. Impact of smoking status on early and late outcomes after isolated coronary artery bypass graft surgery. J Cardiol 61:336–341.
Scandroglio AM, Finco G, Pieri M, et al. 2015. Cardiac surgery in 260 octogenarians: a case series. BMC Anesthesiol 15:15.
Shahian DM, O'Brien SM, Filardo G, et al. 2009. The Society of Thoracic Surgeons 2008 Cardiac Surgery Risk Models: Part 1-Coronary Artery Bypass Grafting. Ann Thorac Surg 88:S2-22.
Shahian DM, O'Brien SM, Filardo G, et al. 2009. The Society of Thoracic Surgeons 2008 Cardiac Surgery Risk Models: Part 3-Valve Plus Coronary Artery Bypass Grafting Surgery. Ann Thorac Surg 88:S43-62.
TIME Investigators. 2001. Trial of invasive versus medical therapy in elderly patients with chronic symptomatic coronary-artery disease (TIME): a randomised trial. Lancet 358:951–957.
Vaughan-Sarrazin MS, Wakefield B, Rosenthal GE. 2007. Mortality of Department of Veterans Affairs patients undergoing coronary revascularization in private sector hospitals. Health Serv Res 42:1802–1821.
Wang DE, Wadhera RK, Bhatt DL. 2018. Association of Rankings With Cardiovascular Outcomes at Top-Ranked Hospitals vs Nonranked Hospitals in the United States. JAMA Cardiol 3:1222-1225.
Wang W, Bagshaw SM, Norris CM, et al. 2014. Association between older age and outcome after cardiac surgery: a population-based cohort study. J Cardiothorac Surg 9:177.
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