Predictors of Decline in Elderly Patients Undergoing TAVI
Predictors of Decline in Elderly Patients Undergoing TAVI
Aims This study aimed to assess functional course in elderly patients undergoing transcatheter aortic valve implantation (TAVI) and to find predictors of functional decline.
Methods and results In this prospective cohort, functional course was assessed in patients ≥70 years using basic activities of daily living (BADL) before and 6 months after TAVI. Baseline EuroSCORE, STS score, and a frailty index (based on assessment of cognition, mobility, nutrition, instrumental and basic activities of daily living) were evaluated to predict functional decline (deterioration in BADL) using logistic regression models. Functional decline was observed in 22 (20.8%) of 106 surviving patients. EuroSCORE (OR per 10% increase 1.18, 95% CI: 0.83–1.68, P = 0.35) and STS score (OR per 5% increase 1.64, 95% CI: 0.87–3.09, P = 0.13) weakly predicted functional decline. In contrast, the frailty index strongly predicted functional decline in univariable (OR per 1 point increase 1.57, 95% CI: 1.20–2.05, P = 0.001) and bivariable analyses (OR: 1.56, 95% CI: 1.20–2.04, P = 0.001 controlled for EuroSCORE; OR: 1.53, 95% CI: 1.17–2.02, P = 0.002 controlled for STS score). Overall predictive performance was best for the frailty index [Nagelkerke's R (NR) 0.135] and low for the EuroSCORE (NR 0.015) and STS score (NR 0.034). In univariable analyses, all components of the frailty index contributed to the prediction of functional decline.
Conclusion Over a 6-month period, functional status worsened only in a minority of patients surviving TAVI. The frailty index, but not established risk scores, was predictive of functional decline. Refinement of this index might help to identify patients who potentially benefit from additional geriatric interventions after TAVI.
Transcatheter aortic valve implantation (TAVI) is an alternative to surgical aortic valve replacement (SAVR) and medical treatment in selected patients with severe aortic stenosis. Transcatheter aortic valve implantation is considered less invasive when compared with SAVR and may therefore be performed in elderly patients at high risk for surgery with favourable effects on mortality and quality of life. However, these outcomes reflect just one part of the clinical outcome in elderly patients. Functional outcomes are similarly important in elderly patients as the functional status of a patient will determine whether the patient is able to live independently or is dependent on the care from another person. The concept of activities of daily living (ADL) is a relevant instrument to measure a person's independence from another person's help. Though ADL represent an important outcome in elderly people, no previous study reported ADL as outcome in patients undergoing TAVI.
Many established risk scores, such as EuroSCORE or Society of Thoracic Surgeons (STS) score, insufficiently assess the risk of elderly co-morbid patients undergoing surgical cardiovascular procedures. For the prediction of mortality after TAVI, it has been previously shown that risk prediction may be improved by adding geriatric risk scores to the established scores. To the best of the authors' knowledge, predictors of a poor functional outcome have not been reported previously. The present study has two objectives: (i) to investigate ADL as relevant outcome in elderly patients undergoing TAVI and (ii) to assess established risk scores as well as baseline functional status as predictors of functional decline.
Abstract and Introduction
Abstract
Aims This study aimed to assess functional course in elderly patients undergoing transcatheter aortic valve implantation (TAVI) and to find predictors of functional decline.
Methods and results In this prospective cohort, functional course was assessed in patients ≥70 years using basic activities of daily living (BADL) before and 6 months after TAVI. Baseline EuroSCORE, STS score, and a frailty index (based on assessment of cognition, mobility, nutrition, instrumental and basic activities of daily living) were evaluated to predict functional decline (deterioration in BADL) using logistic regression models. Functional decline was observed in 22 (20.8%) of 106 surviving patients. EuroSCORE (OR per 10% increase 1.18, 95% CI: 0.83–1.68, P = 0.35) and STS score (OR per 5% increase 1.64, 95% CI: 0.87–3.09, P = 0.13) weakly predicted functional decline. In contrast, the frailty index strongly predicted functional decline in univariable (OR per 1 point increase 1.57, 95% CI: 1.20–2.05, P = 0.001) and bivariable analyses (OR: 1.56, 95% CI: 1.20–2.04, P = 0.001 controlled for EuroSCORE; OR: 1.53, 95% CI: 1.17–2.02, P = 0.002 controlled for STS score). Overall predictive performance was best for the frailty index [Nagelkerke's R (NR) 0.135] and low for the EuroSCORE (NR 0.015) and STS score (NR 0.034). In univariable analyses, all components of the frailty index contributed to the prediction of functional decline.
Conclusion Over a 6-month period, functional status worsened only in a minority of patients surviving TAVI. The frailty index, but not established risk scores, was predictive of functional decline. Refinement of this index might help to identify patients who potentially benefit from additional geriatric interventions after TAVI.
Introduction
Transcatheter aortic valve implantation (TAVI) is an alternative to surgical aortic valve replacement (SAVR) and medical treatment in selected patients with severe aortic stenosis. Transcatheter aortic valve implantation is considered less invasive when compared with SAVR and may therefore be performed in elderly patients at high risk for surgery with favourable effects on mortality and quality of life. However, these outcomes reflect just one part of the clinical outcome in elderly patients. Functional outcomes are similarly important in elderly patients as the functional status of a patient will determine whether the patient is able to live independently or is dependent on the care from another person. The concept of activities of daily living (ADL) is a relevant instrument to measure a person's independence from another person's help. Though ADL represent an important outcome in elderly people, no previous study reported ADL as outcome in patients undergoing TAVI.
Many established risk scores, such as EuroSCORE or Society of Thoracic Surgeons (STS) score, insufficiently assess the risk of elderly co-morbid patients undergoing surgical cardiovascular procedures. For the prediction of mortality after TAVI, it has been previously shown that risk prediction may be improved by adding geriatric risk scores to the established scores. To the best of the authors' knowledge, predictors of a poor functional outcome have not been reported previously. The present study has two objectives: (i) to investigate ADL as relevant outcome in elderly patients undergoing TAVI and (ii) to assess established risk scores as well as baseline functional status as predictors of functional decline.
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