To the Editor:
Whitney et al.
1correctly point out the growing evidence that frailty is a predictor of a variety of complications after surgery and that high-quality evidence for the optimal management of this population has been lacking in the cardiovascular literature. The Canadian Cardiovascular Society (CCS) Guidelines on Perioperative Cardiac Risk Assessment and Management for Patients Who Undergo Noncardiac Surgery is a focused document examining preoperative risk assessment, perioperative risk modification, postoperative monitoring for events, and management of cardiac events (the authors of this article participated on the primary panel of the CCS Guidelines on Perioperative Risk Assessment and Management for Patients Who Undergo Noncardiac Surgery and authored the guidelines document).
- Whitney K.
- Nahid A.
- Power B.
Perioperative cardiac risk assessment for the frail older adult.
Can J Cardiol. 2018; 34: 343.e11
2The primary panel rigorously reviewed the evidence using the Grading of Recommendations Assessment, Development, and Evaluation approach to inform rational decision-making in patients with increased cardiac risk and recognized that evidence will continue to evolve in this area.
- Duceppe E.
- Parlow J.
- MacDonald P.
- et al.
Canadian Cardiovascular Society guidelines on perioperative cardiac risk assessment and management for patients who undergo noncardiac surgery.
Can J Cardiol. 2017; 33: 17-32
Although the Panel did not include routine formal frailty assessment in its recommendations, the guidelines' first parameter to determine the pathway in risk assessment was age; the panel recommended further preoperative assessment by means of cardiac biomarkers in all patients aged 65 years and older. Therefore, according to this schema, all elderly patients are placed in the “at risk” group, and brain natriuretic peptide and N-terminal pro b-type natriuretic peptide screening is advised to guide risk estimation and perioperative monitoring for cardiac events.
- Rodseth R.N.
- Biccard B.M.
- Le Manach Y.
- et al.
The prognostic value of pre-operative and post-operative B-type natriuretic peptides in patients undergoing noncardiac surgery: B-type natriuretic peptide and N-terminal fragment of pro-B-type natriuretic peptide: a systematic review and individual patient data meta-analysis.
J Am Coll Cardiol. 2014; 63: 170-180
A number of frailty indices have been considered in the perioperative setting. However, it remains unproved whether these indices improve the net reclassification index of commonly used and simple indices such as the Revised Cardiac Risk Index (RCRI) and biomarkers regarding cardiovascular outcomes. An 11-point modified frailty index has been developed from the National Surgical Quality Improvement Program database, which shows predictive value for mortality in a number of surgical settings.
4However, 6 of the 11 parameters considered are already encompassed by the RCRI.
- Velanovich V.
- Antoine H.
- Swartz A.
- Peters D.
- Rubinfeld I.
Accumulating deficits model of frailty and postoperative mortality and morbidity: its application to a national database.
J Surg Res. 2013; 183: 104-111
The panel recommended postoperative care of at-risk patients, including elderly patients, by means of shared care models. Although this was a conditional recommendation based on limited evidence, the potential benefits of specialized geriatric care played a strong role in the recommendation.
- Grigoryan K.V.
- Javedan H.
- Rudolph J.L.
Orthogeriatric care models and outcomes in hip fracture patients: a systematic review and meta-analysis.
J Orthop Trauma. 2014; 28: e49-e55
Beyond the scope of the CCS guidelines, frailty predisposes patients to an elevated risk of a number of perioperative complications in addition to cardiac events, and we anticipate with interest the results of continuing investigations in this area.
The authors have no conflicts of interest to disclose.
- Perioperative cardiac risk assessment for the frail older adult.Can J Cardiol. 2018; 34: 343.e11
- Canadian Cardiovascular Society guidelines on perioperative cardiac risk assessment and management for patients who undergo noncardiac surgery.Can J Cardiol. 2017; 33: 17-32
- The prognostic value of pre-operative and post-operative B-type natriuretic peptides in patients undergoing noncardiac surgery: B-type natriuretic peptide and N-terminal fragment of pro-B-type natriuretic peptide: a systematic review and individual patient data meta-analysis.J Am Coll Cardiol. 2014; 63: 170-180
- Accumulating deficits model of frailty and postoperative mortality and morbidity: its application to a national database.J Surg Res. 2013; 183: 104-111
- Orthogeriatric care models and outcomes in hip fracture patients: a systematic review and meta-analysis.J Orthop Trauma. 2014; 28: e49-e55
Published online: December 20, 2017
© 2017 Canadian Cardiovascular Society. Published by Elsevier Inc. All rights reserved.
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- Canadian Cardiovascular Society Guidelines on Perioperative Cardiac Risk Assessment and Management for Patients Who Undergo Noncardiac SurgeryCanadian Journal of CardiologyVol. 33Issue 1
- PreviewThe Canadian Cardiovascular Society Guidelines Committee and key Canadian opinion leaders believed there was a need for up to date guidelines that used the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) system of evidence assessment for patients who undergo noncardiac surgery. Strong recommendations included: 1) measuring brain natriuretic peptide (BNP) or N-terminal fragment of proBNP (NT-proBNP) before surgery to enhance perioperative cardiac risk estimation in patients who are 65 years of age or older, are 45-64 years of age with significant cardiovascular disease, or have a Revised Cardiac Risk Index score ≥ 1; 2) against performing preoperative resting echocardiography, coronary computed tomography angiography, exercise or cardiopulmonary exercise testing, or pharmacological stress echocardiography or radionuclide imaging to enhance perioperative cardiac risk estimation; 3) against the initiation or continuation of acetylsalicylic acid for the prevention of perioperative cardiac events, except in patients with a recent coronary artery stent or who will undergo carotid endarterectomy; 4) against α2 agonist or β-blocker initiation within 24 hours before surgery; 5) withholding angiotensin-converting enzyme inhibitor and angiotensin II receptor blocker starting 24 hours before surgery; 6) facilitating smoking cessation before surgery; 7) measuring daily troponin for 48 to 72 hours after surgery in patients with an elevated NT-proBNP/BNP measurement before surgery or if there is no NT-proBNP/BNP measurement before surgery, in those who have a Revised Cardiac Risk Index score ≥1, age 45-64 years with significant cardiovascular disease, or age 65 years or older; and 8) initiating of long-term acetylsalicylic acid and statin therapy in patients who suffer myocardial injury/infarction after surgery.
- Perioperative Cardiac Risk Assessment for the Frail Older AdultCanadian Journal of CardiologyVol. 34Issue 3