A Practical Two-Stage Frailty Assessment for Older Adults Undergoing Aortic Valve Replacement

Abstract

Objectives: Despite evidence, frailty is not routinely assessed before cardiac surgery. We compared five brief frailty tests for predicting poor outcomes after aortic valve replacement and evaluated a strategy of performing comprehensive geriatric assessment (CGA) in screen-positive patients.

Design: Prospective cohort study.

Setting: A single academic center.

Participants: Patients undergoing surgical aortic valve replacement (SAVR) (n = 91; mean age = 77.8 y) or transcatheter aortic valve replacement (TAVR) (n = 137; mean age = 84.5 y) from February 2014 to June 2017.

Measurements: Brief frailty tests (Fatigue, Resistance, Ambulation, Illness, and Loss of weight [FRAIL] scale; Clinical Frailty Scale; grip strength; gait speed; and chair rise) and a deficit-accumulation frailty index based on CGA (CGA-FI) were measured at baseline. A composite of death or functional decline and severe symptoms at 6 months was assessed.

Results: The outcome occurred in 8.8% (n = 8) after SAVR and 24.8% (n = 34) after TAVR. The chair rise test showed the highest discrimination in the SAVR (C statistic = .76) and TAVR cohorts (C statistic = .63). When the chair rise test was chosen as a screening test (≥17 s for SAVR and ≥23 s for TAVR), the incidence of outcome for screen-negative patients, screen-positive patients with CGA-FI of .34 or lower, and screen-positive patients with CGA-FI higher than .34 were 1.9% (n = 1/54), 5.3% (n = 1/19), and 33.3% (n = 6/18) after SAVR, respectively, and 15.0% (n = 9/60), 14.3% (n = 3/21), and 38.3% (n = 22/56) after TAVR, respectively. Compared with routinely performing CGA, targeting CGA to screen-positive patients would result in 54 fewer CGAs, without compromising sensitivity (routine vs targeted: .75 vs .75; P = 1.00) and specificity (.84 vs .86; P = 1.00) in the SAVR cohort; and 60 fewer CGAs with lower sensitivity (.82 vs.65; P = .03) and higher specificity (.50 vs .67; P < .01) in the TAVR cohort.

Conclusions: The chair rise test with targeted CGA may be a practical strategy to identify older patients at high risk for mortality and poor recovery after SAVR and TAVR in whom individualized care management should be considered. J Am Geriatr Soc 67:2031-2037, 2019.

Keywords: aortic valve replacement; frailty; functional status; preoperative evaluation.

Conflict of interest statement

Conflict of interest:

1. Dr. Popma reports grants to his institution from Medtronic and Boston Scientific, consultant fees from Direct Flow, and fees for serving on a medical advisory board from Boston Scientific.

2. Ms. Guibone reports consultant fees from Medtronic.

3. Other authors declare no disclosures.

© 2019 The American Geriatrics Society.

Figures

Figure 1.. A Two-Stage Frailty Evaluation and Risk of Death and Poor Recovery at 6 Months After Aortic Valve Replacement

Abbreviations: CGA, comprehensive geriatric assessment; SAVR, surgical aortic valve replacement; TAVR, transcatheter aortic valve replacement. Panel A shows a two-stage frailty evaluation using a chair rise test cut-point that achieves 75% sensitivity (≥17 seconds in SAVR cohort and ≥23 seconds in TAVR cohort). CGA is performed in 37 screen-positive patients in SAVR cohort and 77 screen-positive patients in TAVR. Panel B shows a two-stage frailty evaluation using a chair rise test cut-point that achieves 75% specificity (≥23 seconds in SAVR cohort and ≥60 seconds in TAVR cohort). CGA is performed in 25 screen-positive patients in SAVR cohort and 63 screen-positive patients in TAVR cohort.

Figure 2.. A Two-Stage Frailty Evaluation and Functional Status Change Over 12 Months After Aortic Valve Replacement

Abbreviations: CGA-FI, comprehensive geriatric assessment-based frailty index; SAVR, surgical aortic valve replacement; TAVR, transcatheter aortic valve replacement. A composite functional status score indicates the number of 22 daily activities and physical tasks that one can perform without another person’s help (see the list of 22 activities in the text) (higher values indicate better functional status). The means (nodes) and 95% CIs (vertical bars) of composite functional status score were plotted for chair rise screen-negative patients (0.34.