Assessing Risks and Benefits of Invasive Cardiac Procedures in Patients with Advanced Multimorbidity

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Key points

  • Older adults with multimorbidity face increased challenges in choosing to pursue an invasive cardiovascular procedure because their cardiac disease is only one of many concurrent diseases.

  • In older adults, it is often less certain that an invasive cardiac intervention will lead to improvements in symptoms or function because concurrent illnesses or geriatric syndromes may be the principal determinants of the symptoms.

  • Concurrent illnesses or geriatric syndromes in old age are more likely to

The allure of surgery and its limitations in the context of multimorbidity

With the advent of modern medicine, the ability to “fix” has become a mainstay of clinical practice and an expectation from patients. Nowhere is this clearer than in surgery and surgery-like catheter interventions. From the days of Joseph Lister and the introduction of the sterile technique to modern technological advances, surgery has become progressively safer and is commonly considered the ultimate definitive therapy.

A driving aspect of the professional culture of surgeons and cardiologists

Multimorbidity

In the realm of cardiovascular disease the term comorbidity is often used, identifying the cardiovascular disease as central to the patient’s problem list, with all other concurrent diagnoses deemed “comorbid.” However, this fails to recognize that other diagnoses and geriatric syndromes may have equal bearing on the patient’s sense of health and well-being. “Multimorbidity” implies the interactive effects of two or more “primary” disease processes when they occur together.10 Moreover,

Medical complexity and preoperative risk assessment

Clinicians have had a long tradition of trying to gauge relative risks to benefits before invasive procedures. Characterization of risks originally centered on the procedure itself (anesthesia, ventilation, bleeding, infection, and techniques), and then evolved to integrate patient-related considerations. More than 70 years ago anesthesiologists developed the American Society of Anesthesiologist Physical Status. Patients were subtyped based on a subjective assessment of their overall health

Pertinent geriatric perspectives in preoperative assessment

The impact of geriatric domains may often supersede the impact of more traditional parameters of risk, and should be considered as part of preprocedure assessment.

Beyond the procedure

Beyond the immediate procedural risks, broader risks of management are also critical. Early mobility, aspiration pneumonia precautions, and delirium prevention are complementary priorities of care.

Deciding if a cardiac procedure is worth the risk

Predicting who will benefit from a cardiac procedure is notoriously difficult. Life expectancy models have been suggested to help guide clinical decision making.56 Methods such as these are often used to differentiate between chronologic and biologic age.57 A robust 85 year old may be physiologically closer to a 75 year old and conversely a frail 75 year old may physiologically be more similar to an 85 year old, and such perspective may help guide decisions whether or not to pursue surgery

Summary

In the older adult with multimorbidity, the decision to pursue an invasive cardiac procedure is not only limited to the inherent risks of the intervention. Classically operative success has focused on technical, major associated morbidity, and mortality rates; however, in this population, success or failure is often extended beyond these metrics. With advances in technical ability, a patient may survive a procedure, but whether they will derive benefit, and how that benefit is assessed can only

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    Disclosure Statement: Dr D. E. Forman is supported in part by NIA grant P30 AG024827 and VA Office of Rehabilitation Research and Development grant F0834-R.

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