Pre-operative physical performance as a predictor of in-hospital outcomes in older patients undergoing elective cardiac surgery.

OBJECTIVE: Risk stratification of cardiac surgery patients is usually based on the Society of Thoracic Surgeons (STS) score, that has limited predictive value in older persons. We aimed assessing whether the Short Physical Performance Battery (SPPB) improves, beyond the STS score, assessment of hospital prognosis in older patients undergoing elective cardiac surgery. METHODS: All patients aged 75+ years referred for elective cardiac surgery to Careggi University Hospital (Florence, Italy) from April 2013 to March 2017 were evaluated pre-operatively. Participants were classified according to the STS-Predicted Risk Of Mortality (STS-PROM): low (<4%), intermediate (4 to 8%), and high risk (>8%). Primary study outcomes were hospital mortality and STS-defined major morbidity. Length of hospital stay was an additional outcome. RESULTS: Out of 235 participants (females: 46.5%; mean age: 79.6 years), 144 (61.3%) were at low, 67 (28.5%) at intermediate and 24 (10.2%) at high risk, based on the STS-PROM. SPPB (mean±SEM) was 8.8 ± 0.2, 7.0 ± 0.5, and 6.0 ± 0.8 in participants at low, intermediate, and high risk, respectively (p<0.001). The primary outcome occurred in 62 participants (26.4%). In low-risk participants, the SPPB score predicted the primary endpoint (adjusted OR 0.77, 95% CI 0.66-0.89 per each point increase; p<0.001) controlling for STS-Major Morbidity or Operative Mortality (STS-MM) score. This result was not observed in the intermediate-high risk group. CONCLUSIONS: SPPB predicts mortality and major morbidity in older patients undergoing elective cardiac surgery, classified as low risk with the STS risk score. The SPPB, applied preoperatively, might improve risk stratification in older patients undergoing elective cardiac surgery.

Prognostic value of adiponectin in coronary artery disease: Role of diabetes and left ventricular systolic dysfunction.

OBJECTIVES: Adiponectin (AD) promotes insulin sensitivity and has anti-atherogenic properties. However, the role of AD on clinical outcomes in coronary artery disease (CAD) is controversial. We analyzed whether AD was an independent predictor of all-cause mortality and hospitalization in patients with CAD. METHOD: We prospectively enrolled 138 patients with stable CAD, with or without type 2 diabetes and with or without left ventricular dysfunction. A telephone follow-up was conducted to register long term outcomes. Sensitivity/specificity ratio for AD was investigated with ROC analysis and the independent role of AD on outcome was evaluated with Cox regression model of analysis. The survival rate was represented by Kaplan Meyer curves. RESULTS: Of 138 patients, 61 had type 2 diabetes and 71 left ventricular systolic dysfunction (EF<40%). Median time of follow-up was 1384days; mortality rate was 18.8% (26 deaths) and hospitalization rate was 47.1% (65 events). Mean concentration of AD was 9.87±7.53ng/ml; the analysis of the ROC curve identified an AD cut-off level of 13.2ng/ml (AUC 0.779; p<0.0001). Patients with AD >13.2ng/ml had a significantly higher risk of death (HR=6.50; 95% CI: 2.40-17.70), but not of cardiovascular hospitalization (HR=0.87; 95% CI: 0.31-2.44). AD predictivity remained significant also in patients with type 2 diabetes and with left ventricular systolic dysfunction. CONCLUSION: In stable CAD, an AD value of >13.2ng/ml independently predicts a 6-fold increased risk of all-cause mortality.

Age-related impact of depressive symptoms on functional capacity measured with 6-minute walking test in coronary artery disease.

BACKGROUND: Patients affected by coronary artery disease (CAD) have a high prevalence of depressive disorders. It has been suggested that depressive symptoms significantly reduce exercise stress test performance in CAD patients, whereas their influence on functional capacity tests, such as the 6-minute walking test (6WT), has been less investigated. The aim of this study was to evaluate the correlation between depressive symptoms and 6WT in patients with CAD and the role of age on this relationship. METHODS: We enrolled 148 CAD patients. Global functional capacity was measured with 6WT and the presence of depressive symptoms with the 30-item Geriatric Depression Scale (GDS). GDS score was analysed as a continuous variable or categorized as depression absent (score <10), probable (10-14), or present (≤15). RESULTS: A significant inverse correlation was observed between GDS score and distance walked at 6WT. Patients positive for depressive symptoms (probable or present) had a significantly worse performance compared to those with GDS score <10. In multivariable analysis adjusted for indexes of cardiovascular disease severity and comorbidity, the presence of depressive symptoms proved to be an independent predictor of distance walked at 6WT; the predictivity of depressive symptoms on 6WT was age dependent. CONCLUSIONS: Depressive symptoms negatively affect 6WT performance among older CAD subjects. Non-cardiovascular parameters, such as psycho-affective disorders, must be taken into account for the interpretation of 6WT performance in old age.

Epicardial adipose tissue and insulin resistance in patients with coronary artery disease with or without left ventricular dysfunction.

BACKGROUND: Epicardial adipose tissue (EAT) is a visceral fat that fulfills two important functions: lipid-storage and secretion of adipokines with pro-inflammatory and pro-atherogenic properties. It has been suggested that EAT may affect the pathogenesis of atherosclerosis and the clinical course of coronary artery disease (CAD). In patients with obesity, diabetes and metabolic syndrome, the epicardial adipose tissue is enlarged. Little is known about the role of EAT in left ventricular dysfunction. Aim of this study was to evaluate the ability of insulin resistance to predict EAT thickness in patients with significant CAD and systolic dysfunction. METHODS: We enrolled 114 subjects diagnosed with CAD by angiography. The majority underwent revascularization after an acute coronary syndrome. Patients were considered affected by significant left ventricular dysfunction when EF was < or = 40%. Three indexes of insulin resistance, the HOMA IR index, the insulin sensitivity QUICKI index, and the novel adiponectin/resistin index (ADIPO-IRAR) were calculated and correlated to EAT thickness. Epicardial fat was measured by echocardiography according to standardized methods. RESULTS: Subjects with diabetes and with a history of hypercholesterolemia had thicker EAT compared to controls. Potassium levels and all three indexes of insulin resistance were the best independent predictors of EAT in the study population as a whole and in the subset of patients with left ventricular dysfunction. In the latter group the novel ADIPO-IRAR index displayed the strongest predictivity. CONCLUSION: Insulin resistance is an independent predictor of EAT thickness in patients affected by CAD, also in the presence of significant left ventricular dysfunction.

Adiponectin, diabetes and ischemic heart failure: a challenging relationship.

BACKGROUND: Several peptides, named adipokines, are produced by the adipose tissue. Among those, adiponectin (AD) is the most abundant. AD promotes peripheral insulin sensitivity, inhibits liver gluconeogenesis and displays anti-atherogenic and anti-inflammatory properties. Lower levels of AD are related to a higher risk of myocardial infarction and a worse prognosis in patients with coronary artery disease. However, despite a favorable clinical profile, AD increases in relation to worsening heart failure (HF); in this context, higher adiponectinemia is reliably related to poor prognosis. There is still little knowledge about how certain metabolic conditions, such as diabetes mellitus, modulate the relationship between AD and HF.We evaluated the level of adiponectin in patients with ischemic HF, with and without type 2 diabetes, to elucidate whether the metabolic syndrome was able to influence the relationship between AD and HF. RESULTS: We demonstrated that AD rises in patients with advanced HF, but to a lesser extent in diabetics than in non-diabetics. Diabetic patients with reduced systolic performance orchestrated a slower rise of AD which began only in face of overt HF. The different behavior of AD in the presence of diabetes was not entirely explained by differences in body mass index. In addition, NT-proBNP, the second strongest predictor of AD, did not differ significantly between diabetic and non-diabetic patients. These data indicate that some other mechanisms are involved in the regulation of AD in patients with type 2 diabetes and coronary artery disease. CONCLUSIONS: AD rises across chronic heart failure stages but this phenomenon is less evident in type 2 diabetic patients. In the presence of diabetes, the progressive increase of AD in relation to the severity of LV dysfunction is hampered and becomes evident only in overt HF.

[The complexity of risk stratification in older patient candidate to non-cardiac surgery]. / La complessità della stratificazione del rischio nel paziente anziano cardiopatico candidato a chirurgia non cardiaca.

During the last decades the older patients who are candidates for surgery have grown exponentially due to the increase in life expectancy and the surgery technique improvement. Despite this, the mortality remains high and our ability to predict the surgery outcomes continues to be low in the elderly. The main reason is related to different difficulties; we are unable to differentiate properly the chronological from the biological age, and the current surgery and cardiology risk scores are poorly geriatric-oriented. We must underline how the measure of comorbidity during the preoperative evaluation is often limited to a simple count of comorbid conditions, without a more detailed assessment of their severity. On the other hand different comorbidity scores have been validated in geriatric populations showing a good correlation with prognosis, such as the Index of Coexisting Disease-ICED or the Geriatric Index of Comorbidity-GIC. Our predictive deficiency about the outcomes is linked to poor attention for identifying the frail patients that are already at high risk of disability. Recently, the evaluation of frailty is a key target for geriatric medicine, and geriatricians have developed various methods for measuring this parameter and suggesting the physical performance indexes as a reliable surrogate of frailty. Surrogate frailty measures, such as the "gait speed" or the "Short Physical Performance Battery-SPPB" seem to be the valid tools for evaluating older surgery patients due to their simplicity and short administration time. We think that the future challenge will be their widespread use in this specific clinical setting.