Cardiac Surgery Riskier for Those Over 80 Years

This group of seniors, known as octogenarians, makes up an increasing percentage of Americans over the last decade who undergo cardiac surgery for symptomatic relief of chest pain and to prolong survival. Much of the research supporting the benefits of cardiac surgery in elderly patients has not been substantiated in more rigorous trials. And many studies don’t include patients over the age of 80.

The Society of Thoracic Surgeons’ National Cardiac Database from 2002 to 2003 reveals an operative mortality rate of 10.9 percent for patients 80 years and older who underwent valve replacement surgery or a combination of valve and cardiac bypass surgery.

A study designed to examine whether outcomes at the time of hospital discharge were similar for patients over the age of 80 to those younger than 80 years, found that octogenarians have a worse outcome following cardiac surgery than younger patients.

Dr. Mohamed Rady and colleagues at the Mayo Clinic Hospital in Scottsdale, Arizona analyzed the outcomes of 783 patients between January 1999 and December 2001 who were admitted to the hospital for either coronary artery bypass surgery, cardiac valve surgery, or both. The study included 96 patients over the age of 80 years. There research is published in the February issue of the American Heart Journal.

Dr. Rady and his team determined that age was the largest contributor for hospital discharge outcome. Their results showed that octogenarians had a higher risk of death following surgery, 13.5 percent versus 1.3 percent for younger patients. The need for re-operation was greater as well, 7 percent versus 3 percent, and the risk of renal insufficiency and neurological complications was also higher among octogenarians than those younger than 80 years.

Length of stay in the ICU and hospital was longer, and initial charges for hospitalization were higher for octogenarians. Medicare was the primarily health insurance provider for this group, but paid for only 70 percent of the younger group.

The researchers also found that 40 percent of octogenarians were discharged to nursing homes while only 13 percent of younger patients went to nursing homes. The researchers wrote that transfer to a nursing care facility was indicative of a decline in functional capacity and constituted a change in quality of life, particularly if they lived independently at home prior to surgery.

"The study findings suggest that a discussion of the potential need for a nursing care facility and quality-of-life expectations should be part of informed counseling for patients who are octogenarians before they decide to undergo cardiac surgery," wrote Dr. Rady and colleagues.

The researchers also suggest clinicians should be analyzing more critically the cost-effectiveness of cardiac surgical procedures versus medical management for patients over the age of 80 years, particularly because "future Medicare funds are likely to limit the extent of delivery of healthcare."

In the same issue of the American Heart Journal, doctors from the Duke Clinical Research Institute in an editorial wrote, "On one hand, clinicians have an obligation to do all they can to extend life. On the other hand, is there not an age at which point a procedure’s likelihood for ‘meaningful benefit’ is outweighed by its acute risks and possibility of prolonged disability?"

While the editorial by Dr. Jonathan Yager, and Dr. Eric Peterson points out some flaws in the design of the Mayo Clinic study—such as small sample size and the fact that hospitals usually have their own discharge orders that can vary from center to center—the doctors agree that communication with patients about the risks of surgery needs to be improved.

"We can safely say," write Dr. Yager and Dr. Peterson, "that we are doing too little…too little research on the topic [of cardiac surgery for octogenarians] and too little dialog with our patients on the real risks and benefits of procedures."