A two-point strategy to clarify prognosis in >80 year olds experiencing out of hospital cardiac arrest.

BACKGROUND: The global population is aging, with the number of ≥80-year-olds projected to triple over the next 30 years. Rates of out-of-hospital cardiac arrest (OHCA) are also increasing within this age group. METHODS: The Victorian Ambulance Cardiac Arrest Registry was utilised to identify OHCAs in patients aged ≥80 years between 2002-2021. Predictors of survival to discharge were defined and a prognostic score derived from this cohort. RESULTS: 77,628 patients experienced OHCA of whom 25,269 (32.6%) were ≥80 years (80-90 years = 18,956; 90-100 years = 6,148; >100 years = 209). The number of patients ≥80 years increased over time both absolutely (p = 0.002) and proportionally (p = 0.028). 619 (2.4%) patients survived to discharge without change over time. Older ages had no difference in witnessed OHCA status but were less likely to have shockable rhythm (OR 0.50 (95% CI 0.44-0.57) for 90-100-year-olds, OR 0.28 (95% CI 0.12-0.63) for 90-100-year-olds). If OHCA was witnessed and there was a shockable rhythm then survival was 14%; if one factor was present survival was 5-6% and if neither factor was present, survival was 0.09%. These survival rates enabled derivation of a simplified prognostic assessment score - the '15/5/0' score - highly comparable to a previously-published American cohort. CONCLUSIONS: Elderly OHCA rates have increased to one-third of caseload. The most important factors predicting survival were whether the OHCA was witnessed and there was a shockable rhythm. We present a simple two-point '15/5/0' prognostic score defining which patients will gain most from advanced resuscitative measures.

Frailty in patients with aortic stenosis awaiting intervention.

Aortic stenosis (AS) is a common valvular disease in older age. Definitive interventions include surgical aortic valve replacement or transcatheter aortic valve implantation (TAVI). In high-risk patients, frailty is observed in up to 50% awaiting TAVI. Frailty is now an established predictor of outcomes in patients with AS who undergo intervention. There is currently no consensus definition for frailty. It is widely described as a syndrome of loss in physiological reserve predisposing to increased vulnerability for death or dependency. Frailty encompasses a holistic view including domains of physical function, cognition, depression, nutrition and medical comorbidities. Individual components of frailty have been shown to significantly predict mortality, functional recovery and quality of life after TAVI. The addition of frailty components to conventional risk prediction models traditionally used in cardiac surgery has been shown to augment overall prediction for post-operative mortality and morbidity. Identifying patients who are frail at baseline provides an opportunity to modify dynamic aspects of frailty prior to, and after definitive intervention for AS. A multidisciplinary approach including comprehensive geriatric pre-operative assessment will likely become standard of care to identify and optimise frail patients awaiting TAVI. In this review, we discuss the definition and measurement of frailty in patients with AS, evaluate recent data on risk prediction associated with frailty, and outline approaches to optimisation of dynamic components of frailty to improve outcomes after AS intervention.