Cardiorespiratory fitness predicts post-surgical mortality in elderly

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1. Compared to age alone, cardiorespiratory fitness is a superior prognosticator of post-surgical mortality and length of stay in older adults. 

2. Preoperative cardiorespiratory fitness testing allows for selection of low-risk elderly patients who will have a high rate of operative success. 

Evidence Rating Level: 2 (Good) 

Study Rundown: Surgeons and anesthesiologists use more than a dozen tests to assess preoperative risk, but there has not been good evidence to support any standardized assessment in the geriatric population. This study links cardiorespiratory fitness and specifically a high anaerobic threshold to lower postsurgical mortality as well as ICU and hospital stay. Anaerobic threshold is defined as the point when lactate production by anaerobic metabolism overtakes lactate removal from the bloodstream. Age, on the other hand, was a poor independent predictor of mortality, although older age in addition to poor cardiorespiratory fitness was associated with a significantly higher mortality. Although this study was prospective and enrolled a large number of patients undergoing major abdominal surgeries, it was limited by its restriction to one medical center as well as its cohort design. A multi-center randomized controlled trial would provide most definitive results for altering clinical guidelines.

Click to read the study in Annals of Surgery

Click to read the accompanying editorial “The Holy Grail of Geriatric Surgery” in Annals of Surgery

In-Depth [prospective cohort study]:  This study enrolled 389 patients who underwent standardized preoperative cardiopulmonary exercise testing prior to a major hepatobiliary operation. Mean age of the patients was 65.8 and the male to female ratio was about equal. Their surgeries were elective, but extensive consisting of liver resections, Whipple’s procedures and retroperitoneal sarcoma resections. The most significant independent predictor of mortality was anaerobic threshold, while age did not predict the likelihood of death. Age however, did increase the importance of anaerobic threshold in predicting mortality: patients over 75 years old with poor cardiorespiratory fitness had 22% risk of postoperative mortality and younger patients with similarly poor fitness were at half of the risk. Comparatively, patients with good cardiorespiratory fitness regardless of age had a much lower risk of mortality at less than 5%. In terms of morbidity, length of hospital and critical care stay were both significantly associated with cardiorespiratory fitness but only length of hospital stay was predicted by age.

By Asya Ofshteyn and Allen Ho

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