Coronary Artery Bypass Grafting (CABG) In Elderly People
John Sedkey Yousef Awad;
Abstract
There have been remarkable advancements in the strategies for prevention and treatment of coronary artery disease. Use of drugs like statins and angiotensin-converting enzyme inhibitors has reduced death and disability in millions. This, coupled with state-of-the-art catheterbased interventions, mainly stent technology, have advanced the age at which patients present for coronary artery bypass grafting (CABG) operations.
Age-related changes occur in small and large vessels and in the heart itself, reducing physiological reserves. Most patients show no signs of impaired haemodynamic performance at baseline, but stresses of anaesthesia will often uncover their limited cardiac reserve.
Older age is usually considered a surrogate for diminished physiological reserve and increased incidence of medical co-morbidities.
The aging surgical population, not unexpectedly, has a relatively greater prevalence of cerebrovascular disease, left ventricular dysfunction, diabetes mellitus, chronic obstructive pulmonary disease, renal impairment and peripheral vascular disease. Therefore, such elderly people with multiple comorbidities tend to have a high rate of complications and cost after CABG.
Not surprisingly, older age is a predictor of increased risk after CABG . This is an important issue since an increasing number of elderly patients (≥70 years of age) are undergoing CABG.
A report evaluated the outcome of patients ≥80 years of age who underwent CABG Compared to younger patients, octogenarians have significantly higher rates of in-hospital mortality and stroke after CABG. After adjustment of comorbidities, age ≥80 was an independent predictor of mortality.
Despite magnified perioperative and postoperative dangers, symptom relief occurs in most patients. Long-term survival and quality of life are also preserved or enhanced in the majority. Clinicians must understand the normal physiological changes associated with ageing in order to construct a risk-benefit analysis that is specifically tailored to each patient. This analysis should take into account a patient’s life expectancy and quality of life both before and after a procedure, and not just age alone. Discrepancies between chronological age and biological age must be dealt with. Most important among all is that these issues must be discussed with the patients and their families. Hence, it is up to the patient and the clinician to explore the potential benefits of an improved quality of living with the attendant risks of the procedure versus alternative treatment. Advanced age alone should not be a deterrent for coronary artery bypass surgery if it has been determined that these benefits outweigh the potential risk.
Survivors among octogenarians who underwent isolated CABG were found to have an excellent quality of life for upto 5 years after surgery.
CABG is generally considered safe because of better surgical techniques and pharmacological facilities available. Despite higher preoperative risks, symptom relief occurs in most elderly patients. Long term survival and quality of life are also good in the majority of elderly patients. Therefore, risk benefit profile should be individualised, and each elderly patient must be assessed on his or her own merit. An elderly person with few background illnesses and a good expected quality and length of life is expected to benefit from CABG. On the other hand, an elderly with several comorbidities and an expected suboptimal quality of life after surgery would probably be best managed conservatively. Therefore, once important risk factors are defined, objective criteria could be established to select the patient for operation. Refined preoperative preparation can be possible and postoperative care could be improved in these elderly patients.
Coronary artery bypass grafting in the elderly is potentially rewarding. Meticulous selection of these patients can help maximizing the benefit of surgery. In this situation, preoperative functional class cannot serve as the sole variable in deciding on surgery. Diabetes mellitus, renal failure, and left ventricular dysfunction must be considered before a decision to operate is made; however, the exact roles of these factors must be evaluated by further studies to help surgeons take such difficult decisions on even firmer criteria.
Less invasive surgical techniques using laparoscopy and robotics through smaller "key hole" incisions with specialized instruments have been applied to many abdominal, urologic, and gynecologic procedures. These alternative approaches are safe and effective, resulting in a reduction in patient discomfort and hospital length of stay and cost. There is increasing experience with the use of similar techniques to open cardiac surgery leading to safer surgery especially in high risk patients like octogenarians.
Age-related changes occur in small and large vessels and in the heart itself, reducing physiological reserves. Most patients show no signs of impaired haemodynamic performance at baseline, but stresses of anaesthesia will often uncover their limited cardiac reserve.
Older age is usually considered a surrogate for diminished physiological reserve and increased incidence of medical co-morbidities.
The aging surgical population, not unexpectedly, has a relatively greater prevalence of cerebrovascular disease, left ventricular dysfunction, diabetes mellitus, chronic obstructive pulmonary disease, renal impairment and peripheral vascular disease. Therefore, such elderly people with multiple comorbidities tend to have a high rate of complications and cost after CABG.
Not surprisingly, older age is a predictor of increased risk after CABG . This is an important issue since an increasing number of elderly patients (≥70 years of age) are undergoing CABG.
A report evaluated the outcome of patients ≥80 years of age who underwent CABG Compared to younger patients, octogenarians have significantly higher rates of in-hospital mortality and stroke after CABG. After adjustment of comorbidities, age ≥80 was an independent predictor of mortality.
Despite magnified perioperative and postoperative dangers, symptom relief occurs in most patients. Long-term survival and quality of life are also preserved or enhanced in the majority. Clinicians must understand the normal physiological changes associated with ageing in order to construct a risk-benefit analysis that is specifically tailored to each patient. This analysis should take into account a patient’s life expectancy and quality of life both before and after a procedure, and not just age alone. Discrepancies between chronological age and biological age must be dealt with. Most important among all is that these issues must be discussed with the patients and their families. Hence, it is up to the patient and the clinician to explore the potential benefits of an improved quality of living with the attendant risks of the procedure versus alternative treatment. Advanced age alone should not be a deterrent for coronary artery bypass surgery if it has been determined that these benefits outweigh the potential risk.
Survivors among octogenarians who underwent isolated CABG were found to have an excellent quality of life for upto 5 years after surgery.
CABG is generally considered safe because of better surgical techniques and pharmacological facilities available. Despite higher preoperative risks, symptom relief occurs in most elderly patients. Long term survival and quality of life are also good in the majority of elderly patients. Therefore, risk benefit profile should be individualised, and each elderly patient must be assessed on his or her own merit. An elderly person with few background illnesses and a good expected quality and length of life is expected to benefit from CABG. On the other hand, an elderly with several comorbidities and an expected suboptimal quality of life after surgery would probably be best managed conservatively. Therefore, once important risk factors are defined, objective criteria could be established to select the patient for operation. Refined preoperative preparation can be possible and postoperative care could be improved in these elderly patients.
Coronary artery bypass grafting in the elderly is potentially rewarding. Meticulous selection of these patients can help maximizing the benefit of surgery. In this situation, preoperative functional class cannot serve as the sole variable in deciding on surgery. Diabetes mellitus, renal failure, and left ventricular dysfunction must be considered before a decision to operate is made; however, the exact roles of these factors must be evaluated by further studies to help surgeons take such difficult decisions on even firmer criteria.
Less invasive surgical techniques using laparoscopy and robotics through smaller "key hole" incisions with specialized instruments have been applied to many abdominal, urologic, and gynecologic procedures. These alternative approaches are safe and effective, resulting in a reduction in patient discomfort and hospital length of stay and cost. There is increasing experience with the use of similar techniques to open cardiac surgery leading to safer surgery especially in high risk patients like octogenarians.
Other data
| Title | Coronary Artery Bypass Grafting (CABG) In Elderly People | Other Titles | ترقيع الشرايين التاجية في كبار الســـــن | Authors | John Sedkey Yousef Awad | Issue Date | 2013 |
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