Judson B. Williams|Karen P. Alexander|Jean?François Morin|Yves Langlois|Nicolas Noiseux|Louis P. Perrault|Kim G Smolderen|Suzanne V. Arnold|Mark J. Eisenberg|Louise Pilote|Johanne Monette|Howard Bergman|Peter K. Smith|Jonathan Afilalo
Preoperative Anxiety as a Predictor of Mortality and Major Morbidity in Patients Aged &gt;70 Years Undergoing Cardiac Surgery
Clinical Research Institute|Duke Medical Center|Clinical Research Institute|Duke Medical Center|Jewish General Hospital|McGill University|Jewish General Hospital|McGill University|Centre Hospitalier de l’Université de Montréal|Montreal Heart Institute|Université de Montréal|Saint Luke's Hospital|Tilburg University|Saint Luke's Hospital|Jewish General Hospital|McGill University|McGill University Health Centre|Jewish General Hospital|McGill University|Jewish General Hospital|McGill University|Duke Medical Center|Jewish General Hospital|McGill University
present study examined association patientreported anxiety postcardiac surgery mortality major morbidity frailty assessment cardiac surgery prospective multicenter cohort study elderly patients undergoing cardiac surgery coronary artery bypass surgery andor valve repair replacement 4 tertiary care hospitals 2008 2009 patients evaluated mean 2 days preoperatively hospital anxiety depression scale validated questionnaire assessing depression anxiety hospitalized patients primary predictor variable high level anxiety defined hospital anxiety depression scale score 11 main outcome measure allcause mortality major morbidity eg stroke renal failure prolonged ventilation deep sternal wound infection reoperation occurring index hospitalization multivariable logistic regression analysis examined association high preoperative anxiety allcause mortalitymajor morbidity adjusting society thoracic surgeons predicted risk age gender depression symptoms total 148 patients mean age 758 44 years 34 women completed hospital anxiety depression scale high levels preoperative anxiety present 7 patients differences found type surgery society thoracic surgeons predicted risk across preoperative levels anxiety adjusting potential confounders high preoperative anxiety remained independently predictive postoperative mortality major morbidity odds ratio 51 95 confidence interval 13 202 p 002 conclusion although high levels anxiety present patients anticipating cardiac surgery conferred strong independent heightened risk mortality major morbidity present study examined association patientreported anxiety postcardiac surgery mortality major morbidity frailty assessment cardiac surgery prospective multicenter cohort study elderly patients undergoing cardiac surgery coronary artery bypass surgery andor valve repair replacement 4 tertiary care hospitals 2008 2009 patients evaluated mean 2 days preoperatively hospital anxiety depression scale validated questionnaire assessing depression anxiety hospitalized patients primary predictor variable high level anxiety defined hospital anxiety depression scale score 11 main outcome measure allcause mortality major morbidity eg stroke renal failure prolonged ventilation deep sternal wound infection reoperation occurring index hospitalization multivariable logistic regression analysis examined association high preoperative anxiety allcause mortalitymajor morbidity adjusting society thoracic surgeons predicted risk age gender depression symptoms total 148 patients mean age 758 44 years 34 women completed hospital anxiety depression scale high levels preoperative anxiety present 7 patients differences found type surgery society thoracic surgeons predicted risk across preoperative levels anxiety adjusting potential confounders high preoperative anxiety remained independently predictive postoperative mortality major morbidity odds ratio 51 95 confidence interval 13 202 p 002 conclusion although high levels anxiety present patients 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elderly patients awaiting coronary artery bypass grafting andor valve repair replacement consecutive patients screened study inclusion 2008 2009 4 universityaffiliated tertiary care centers united states canada part frailty assessment cardiac surgery frailty abcs study9afilalo j eisenberg mj morin jf bergman h monette j noiseux n perrault lp alexander kp langlois dendukuri n et algait speed incremental predictor mortality major morbidity elderly patients undergoing cardiac surgeryj coll cardiol 2010 56 16681676abstract full text full text pdf pubmed scopus 583 google scholar eligible patients asked study personnel complete structured questionnaire included hads brief battery physical performance tests minimental state examinations also administered patients asked grade overall health status frailty criteria determined according cardiovascular health study chs scale10fried lp tangen cm walston j newman ab hirsch c gottdiener j seeman tracy r kop wj burke g mcburnie cardiovascular health study collaborative research groupfrailty older adults evidence phenotypej gerontol biol sci med sci 2001 56 m146m156crossref pubmed google scholar inclusion criteria age 70 years scheduled undergo coronary artery bypass grafting andor valve replacement repair traditional midline sternotomy exclusion criteria included following emergent surgery defined surgery ongoing refractory cardiac compromise delay clinical instability defined active coronary ischemia decompensated heart failure acute process causing significant symptoms abnormal vital signs severe neuropsychiatric condition causing inability cooperate study procedures cancellation patients planned surgery treating physicians unaware results hads influence perioperative care present report prepared keeping standards set forth strengthening reporting observational studies epidemiology strobe statement11von elm e altman dg egger pocock sj gotzsche pc vandenbroucke jp strengthening reporting observational studies epidemiology strobe statement guidelines reporting observational studiesann intern med 2007 147 573577crossref pubmed scopus 4463 google scholar institutional review board enrolling center approved study proceeding patient enrollment data acquisition patients provided written informed consent participate present study hads brief userfriendly selfreport questionnaire developed zigmond snaith12zigmond snaith rp hospital anxiety depression scaleacta psychiat scand 1983 67 361370crossref pubmed scopus 33562 google scholar 1983 assess levels anxiety depression among patients nonpsychiatric hospitals selfreport scale administered patients approximately 5 minutes scored approximately 1 minute hads repeatedly validated shown perform well screening tool assessing presence symptom severity anxiety disorders depression13bjelland dahl aa haug tt neckelmann validity hospital anxiety depression scale updated literature reviewj psychosom res 2002 52 6977abstract full text full text pdf pubmed scopus 7310 google scholar 14osborne rh elsworth gr sprangers oort fj hopper jl value hospital anxiety depression scale hads comparing women early onset breast cancer populationbased reference womenqual life res 2004 13 191206crossref pubmed scopus 93 google scholar hads translated many languages validation studies confirming international applicability questionnaire15herrmann c international experiences hospital anxiety depression scalea review validation data clinical resultsj psychosom res 1997 42 1741abstract full text pdf pubmed scopus 2324 google scholar present study hads questionnaires administered english french hads questionnaire consists 14 items 7 2 subscales anxiety hadsa depression hadsd item rated 0 3 4point likert scale resulting potential range scores 0 21 subscale score 11 either subscale considered indicate cases significant psychological morbidity scores 8 10 represent possible anxiety 0 7 represent anxiety designed use inpatient setting individual hads items formulated symptoms referring previous 7 days include physical indexes psychological distress might expected result falsepositive results among hospitalized patients key phrases questions including hadsa subscale listed table 1table 1anxiety questions hospital anxiety depression scalethe complete hads available original 1983 report zigmond snaith12questionhow often past week a1feel tense wound upa2get sort frightened feeling something awful happena3have worrying thoughts go minda4sit ease feel relaxeda5get sort frightened feeling like butterflies stomacha6feel restless movea7get sudden feelings panic complete hads available original 1983 report zigmond snaith12zigmond snaith rp hospital anxiety depression scaleacta psychiat scand 1983 67 361370crossref pubmed scopus 33562 google scholar open table new tab primary outcome measure incidence mortality major morbidity occurring cardiac surgery index hospitalization society thoracic surgeons sts database definitions used outcomes outcomes death defined mortality cause stroke central neurologic deficit persisting 72 hours renal failure new dialysis requirement increase serum creatinine 2 mgdl twofold greater preoperative level prolonged ventilation need mechanical ventilation 24 hours deep sternal wound infection reoperation reason secondary outcome measures discharge healthcare facility ongoing medical care rehabilitation prolonged postoperative length stay defined sts standard 14 days surgery physicians ascertaining outcomes medical records unaware results hads questionnaire demographic operative characteristics compared across categories hadsa scores 0 7 anxiety 8 10 possible anxiety 11 anxiety categorical variables presented percentages continuous variables presented median 25th 75th percentiles comparisons baseline variables conducted using nonparametric wilcoxon rank sum test multivariable analyses performed logistic regression modeling reported odds ratios ors 95 confidence intervals cis number risk factors patients undergoing cardiac surgery 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scores score specifically designed predict inhospital mortality major morbidity precise primary end point present study sensitivity analysis using nonparsimonious model adjusted additional covariates performed ensure significant confounding overlooked performance model assessed addition hadsa score determine incremental value model discrimination reflecting ability assign greater predicted risk observed outcome measured area receiver operating characteristic curve cstatistic21hosmer lemeshow applied logistic regression2nd ed wiley interscience new york new york2000crossref google scholar sensitivity analyses hadsa score represented continuous variable also performed analyses performed stata version 11 statacorp college station texas cohort analyses consisted 148 patients completed hads questionnaire underwent cardiac surgery within frailty abcs study median interval questionnaire completion surgery 2 days interquartile range 1 3 patients lost followup figure 1 displays flow patients present study baseline variables stratified hadsa score listed table 2 71 scored 0 7 anxiety 22 scored 8 10 possible anxiety 7 scored 11 21 anxiety group age gender included individually along sts risk score multivariable model patients anxiety less likely university level education 3 hads groups markedly different procedure type median stspromm 17 16 15 anxiety possible anxiety anxiety groups respectively table 2table 2baseline variables stratified hospital anxiety depression scaleanxiety hadsa scorevariableno anxiety hadsa 07 n 105possible anxiety hadsa 810 n 32anxiety hadsa 1121 n 11age yrs75 72 7976 73 8076 71 79women29 2817 534 36living alone30 299 284 36universitylevel education34 328 251 9general perception health good29 284 130 0 good47 4512 385 45 fair27 2610 314 36 poor2 26 191 18body mass index kgm226 24 2927 23 3027 26 30diabetes mellitus39 3713 414 36hypertension75 7126 818 73dyslipidemia67 6422 699 82current past smoker59 5620 625 45chronic heart failure30 299 282 18left ventricular ejection fraction 55 45 6060 54 6555 35 65atrial fibrillation17 164 133 27chronic renal failure19 186 192 18stroke12 113 91 9history anxiety6 62 60 0history depression5 52 61 9hospital anxiety depression scale depression score 112 1 44 2 78 6 10minimental state examination score 3027 23 2928 26 2927 25 29frailty cardiovascular health study scale16 159 285 45surgery type isolated coronary artery bypass grafting64 6118 568 73 valve procedure without coronary artery bypass grafting41 3914 443 27urgent surgery56 5320 635 45society thoracic surgeons predicted risk mortality major morbidity 17 11 2616 13 2115 10 23society thoracic surgeons predicted risk mortality 3 1 42 2 32 1 4logistic euroscore7 4 128 5 146 4 9data presented n value quartile 1 quartile 3 open table new tab data presented n value quartile 1 quartile 3 median minimental state examination score 27 30 normal range without differences across 3 hadsa groups existing diagnosis depression often present patients anxiety median hadsd score 2 4 8 anxiety possible anxiety anxiety groups respectively table 2 clinical outcomes according hadsa score listed table 3 composite end point mortality major morbidity occurred 22 anxiety group 25 possible anxiety group 55 anxiety group inhospital mortality across 3 hadsa score groups anxiety possible anxiety anxiety group 4 6 9 respectively discharge healthcare facility nursing home convalescence rehabilitation facility also increased increasing anxietytable 3inhospital outcomes anxiety groupsoutcomesno anxiety hadsa 07 n 105possible anxiety hadsa 810 n 32anxiety hadsa 1121 n 11mortality major morbidity23 228 256 55mortality4 42 61 9prolonged length stay 14 days25 2412 383 28discharge healthcare facility28 2814 475 50 open table new tab relation measured hadsa score adverse events demonstrated threshold effect rather graded linear response receiver operating characteristic analysis performed identify optimal threshold cutoff showed hadsa score 11 predictive mortality major morbidity cohort elderly patients undergoing cardiac surgery 76 patients correctly classified cutoff keeping established norms recommended categorizing hadsa score 0 7 anxiety 8 10 possible anxiety 11 anxiety univariate logistic regression analysis hadsa score considered dichotomous variable score 11 signifying anxiety vs score 11 signifying possible anxiety unadjusted mortality major morbidity 41 95 ci 12 144 p 0027 adjusting stspromm age gender hadsd score adjusted mortality major morbidity 51 95 ci 13 202 p 002 table 4 figure 2 demonstrates given stspromm sts risk score predicted risk according regression model greater patients anxiety hadsa score 11 compared patients anxiety possible anxiety hadsa score 11table 4multivariable model predict mortality major morbidityor 95 cip valuesociety thoracic surgeons predicted risk mortality major morbidity106 101110001age102 093112062female gender349 1527990003depression hospital anxiety depression scaledepression score 11128 025659077anxiety hospital anxiety depression scaleanxiety score 1151 127202002ci confidence interval odds ratio open table new tab ci confidence interval odds ratio sensitivity analyses hadsa score represented continuous variable confirmed results similar presented table 4 additional sensitivity analysis performed using nonparsimonious model adjusted frailty education level suggest evidence residual confounding anxiety unchanged additional variables added model present prospective multicenter study significant levels patientreported preoperative anxiety independently predicted greater risk inhospital mortality major morbidity elderly patients undergoing cardiac surgery increased hazard persisted even adjustment surgical risk sts risk score related traditional risk factors depressive symptoms majority patients high levels anxiety unlikely clinical diagnosis general anxiety disorder importantly high levels anxiety potentially modifiable identifying patients could provide opportunity increase psychological comfort improve clinical outcomes highrisk group relationship preexisting anxiety outcomes cardiac surgery clearly defined likely owing part small size previous studies variations anxiety definitions ie anxiety disorder symptoms trait anxiety failure consider depression anxiety simultaneously22hoen pw whooley martens ej na b van melle jp de jonge p differential associations specific depressive symptoms cardiovascular prognosis patients stable coronary heart diseasej coll cardiol 2010 56 838844abstract full text full text pdf pubmed scopus 90 google scholar 23rothenbacher hahmann h wusten b koenig w brenner h symptoms anxiety depression patients stable coronary heart disease prognostic value consideration pathogenetic linkseur j cardiovasc prev rehabil 2007 14 547554crossref pubmed scopus 82 google scholar found anxiety days preceding surgery among hospitalized elderly patients associated greater risk mortality major morbidity adjusting sts risk score also symptoms preoperative depression measured hadsd questionnaire particularly relevant given previous studies explicitly test coexisting anxiety7blumenthal ja lett hs babyak white w smith pk mark db jones r mathew jp newman mf norg investigators depression risk factor mortality coronary artery bypass surgerylancet 2003 362 604609abstract full text full text pdf pubmed scopus 537 google scholar depression lesser extent anxiety known risk factors progressive cardiovascular disease among medically managed outpatients2gullette ec blumenthal ja babyak jiang w waugh ra frid dj oconnor cm morris jj krantz ds effects mental stress myocardial ischemia daily lifejama 1997 277 15211526crossref pubmed google scholar 24greillier l thomas p loundou doddoli c badier auquier p barlsi f prediction cardiac surgery outcome based upon preoperative psychological factorspsychology health 1996 11 471477crossref scopus 34 google scholar study 1054 patients stable coronary artery disease completing hads questionnaire rothenbacher et al23rothenbacher hahmann h wusten b koenig w brenner h symptoms anxiety depression patients stable coronary heart disease prognostic value consideration pathogenetic linkseur j cardiovasc prev rehabil 2007 14 547554crossref pubmed scopus 82 google scholar simultaneously considered anxiety depressive symptom scores relation adverse cardiovascular events 3year followup similar study anxiety associated increased risk cardiovascular events hazard ratio 33 95 ci 13 83 depressive symptoms associated nonsignificant risk hazard ratio 062 95 ci 020 187 among patients undergoing surgical treatment23rothenbacher hahmann h wusten b koenig w brenner h symptoms anxiety depression patients stable coronary heart disease prognostic value consideration pathogenetic linkseur j cardiovasc prev rehabil 2007 14 547554crossref pubmed scopus 82 google scholar several pathophysiologic processes proposed explain negative relation anxiety adverse events including hypercortisolemia insulin resistance sympathetic vagal disturbance lifestyle risk factors including cigarette smoking25tully pj baker ra knight jl anxiety depression risk factors mortality coronary artery bypass surgeryj psychosom res 2008 64 285290abstract full text full text pdf pubmed scopus 128 google scholar 26carney rm freedland ke miller ge jaffe depression risk factor cardiac mortality morbiditya review potential mechanismsj psychosom res 2002 53 897902abstract full text full text pdf pubmed scopus 609 google scholar 27cohen marmar c ren l bertenthal seal kh association cardiovascular risk factors mental health diagnoses iraq afghanistan war veterans using va health carejama 2009 302 489492crossref pubmed scopus 139 google scholar increased anxiety could stem low health literacy lower educational status results unfamiliarity healthcare environment cases patients feel anxious illatease likely unable adhere postprocedural plan care resulting adverse events explanation would represent potentially modifiable process results present study relevance clinical care administration simple hads questionnaire might warrant additional study use rapid bedside diagnostic orientation quick evaluation anxiety symptoms part preoperative workup might allow identification highrisk patients pharmacologic psychotherapeutic interventions could instituted moreover stress management educational intervention services offered many hospitals resources could used appropriately identified cardiac surgical inpatients recent published studies suggested cardiovascular procedures myocardial infarction might underused patients mental health disorders28druss bg bradford dw rosenheck ra radford mj krumholz hm mental disorders use cardiovascular procedures myocardial infarctionjama 2000 283 506511crossref pubmed scopus 440 google scholar caution readers interpret findings barrier delivery evidencebased care instead observations encourage recognition preoperative anxiety among elderly patients cardiac surgery promote collaboration among cardiovascular physicians psychiatric services reduce emotional tension perhaps improve postcardiac surgery outcomes present study several important limitations first observational study causality cannot inferred effects unknown confounders observed associations cannot excluded second patients high levels anxiety reported slightly lower overall health status suggesting something health might captured clinical variables including sts risk score thus anxiety symptoms might act surrogate sick vulnerable patients captured sts risk score third although adjusted depression symptoms comorbid state using hadsd severity depression considered fourth previous current use antidepressants anxiolytics psychiatric services assessed finally although multiinstitutional multinational study findings remain validated larger external data set particularly younger patients anxiety depression predictors cardiovascular outcomes cardiac surgeryamerican journal cardiologyvol 111issue 7previewwe read article williams et al1 curiously suggest relation preexisting anxiety cardiac surgery outcomes clearly defined fact referring past failure consider depression anxiety simultaneously putting alleged past failure appropriate context several studies published past 6 years elucidated simultaneous role anxiety depression respect various cardiac surgery outcomes210 overlooking previous studies would conspicuous williams