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Canadian Journal of Cardiology

Considerations in Cardiac Revascularization for the Elderly Patient: Age Isn't Everything

      Abstract

      Coronary artery disease is the leading cause of morbidity and mortality even in the elderly population. Treatment opportunities in the elderly population are often underappreciated. Revascularization procedures (coronary artery bypass graft surgery and percutaneous coronary intervention) can be associated with important benefits in symptom control, quality of life, and long-term mortality, at an upfront cost of an increased risk of in-hospital mortality and morbidity. Risk models to assess periprocedural risk are useful. The best models would balance unique aspects of risk with the very real potential benefit of revascularization. Current models fall short in this regard. Frailty, a clinical syndrome of vulnerability, is present in 25%-50% of cardiac patients, and is associated with increased morbidity and mortality. The addition of frailty can improve the discrimination of risk models. Elderly patients commonly consider quality of life to have greater importance than mortality outcomes. Furthermore, hospital admission is associated with a reduction in mobilization, loss of muscle strength, and worsening frailty, and interferes with a fundamental value in the elderly: the maintenance of independence. Therefore, an understanding of frailty, quality of life, and other unique aspects of risk, as well as individual patient goals, can assist in further defining prognosis and refine decision-making in this important and vulnerable population.

      Résumé

      La coronaropathie est la cause principale de morbidité et de mortalité, même dans la population âgée. On sous-évalue souvent les possibilités de traitement de cette population âgée. Les interventions de revascularisation (pontage aortocoronarien et intervention coronarienne percutanée) peuvent être associées à des avantages importants dans la maîtrise des symptômes, la qualité de vie et la mortalité à long terme au coût d’une augmentation en amont du risque de mortalité intrahospitalière et de morbidité. Les modèles de risque qui évaluent le risque péri-interventionnel sont utiles. Les meilleurs modèles équilibreraient les aspects particuliers du risque avec l’avantage très réel de la revascularisation. Les modèles actuels ne suffisent pas à cet égard. La fragilité, un syndrome clinique de vulnérabilité, est présente chez 25 % à 50 % des patients cardiaques, et est associée à l’augmentation de la morbidité et de la mortalité. L’ajout de la fragilité peut améliorer la discrimination des modèles de risque. Les patients âgés considèrent fréquemment la qualité de vie comme étant plus importante que les résultats de mortalité. De plus, l’hospitalisation est associée à une réduction de la mobilité, à la perte de la force musculaire et à une plus grande fragilité, et touche à une valeur fondamentale chez les personnes âgées: le maintien de l’autonomie. Par conséquent, la compréhension de la fragilité, de la qualité de vie et des autres aspects particuliers du risque ainsi que des objectifs individuels des patients peut aider à mieux établir le pronostic et à affiner la prise de décision chez cette population importante et vulnérable.
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