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Preoperative Anxiety as a Predictor of Mortality and Major Morbidity in Patients Aged >70 Years Undergoing Cardiac Surgery

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The present study examined the association between patient-reported anxiety and postcardiac surgery mortality and major morbidity. Frailty Assessment Before Cardiac Surgery was a prospective multicenter cohort study of elderly patients undergoing cardiac surgery (coronary artery bypass surgery and/or valve repair or replacement) at 4 tertiary care hospitals from 2008 to 2009. The patients were evaluated a mean of 2 days preoperatively with the Hospital Anxiety and Depression Scale, a validated questionnaire assessing depression and anxiety in hospitalized patients. The primary predictor variable was a high level of anxiety, defined by a Hospital Anxiety and Depression Scale score of ≥11. The main outcome measure was all-cause mortality or major morbidity (e.g., stroke, renal failure, prolonged ventilation, deep sternal wound infection, or reoperation) occurring during the index hospitalization. Multivariable logistic regression analysis examined the association between high preoperative anxiety and all-cause mortality/major morbidity, adjusting for the Society of Thoracic Surgeons predicted risk, age, gender, and depression symptoms. A total of 148 patients (mean age 75.8 ± 4.4 years; 34% women) completed the Hospital Anxiety and Depression Scale. High levels of preoperative anxiety were present in 7% of patients. No differences were found in the type of surgery and Society of Thoracic Surgeons predicted risk across the preoperative levels of anxiety. After adjusting for potential confounders, high preoperative anxiety was remained independently predictive of postoperative mortality or major morbidity (odds ratio 5.1, 95% confidence interval 1.3 to 20.2; p = 0.02). In conclusion, although high levels of anxiety were present in few patients anticipating cardiac surgery, this conferred a strong and independent heightened risk of mortality or major morbidity.

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Methods

Consecutive patients were screened for study inclusion from 2008 to 2009 at 4 university-affiliated tertiary care centers in the United States and Canada as a part of the Frailty Assessment Before Cardiac Surgery (Frailty ABC'S) study.9 Eligible patients were asked by the study personnel to complete a structured questionnaire that included the HADS and a brief battery of physical performance tests. Mini-mental state examinations were also administered, and patients were asked to grade their

Results

The cohort for these analyses consisted of 148 patients who completed the HADS questionnaire and underwent cardiac surgery within the Frailty ABC'S study. The median interval from questionnaire completion to surgery was 2 days (interquartile range 1 to 3). No patients were lost to follow-up. Figure 1 displays the flow of patients through the present study. The baseline variables stratified by HADS-A score are listed in Table 2: 71% scored 0 to 7 (“no anxiety”); 22% scored 8 to 10 (“possible

Discussion

In the present prospective multicenter study, significant levels of patient-reported preoperative anxiety independently predicted a greater risk of in-hospital mortality or major morbidity in elderly patients undergoing cardiac surgery. This increased hazard persisted even after adjustment for surgical risk (STS risk score) related to traditional risk factors and depressive symptoms. The majority of patients with high levels of anxiety were unlikely to have a clinical diagnosis of general

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    Dr. Williams was supported in part by training grant T32-HL069749 from the National Institutes of Health (Bethesda, Maryland) and Drs. Williams, Smith, and Perrault were supported in part by grant U01-HL088953 from the National Institutes of Health Cardiothoracic Surgical Trials Network (Bethesda, Maryland).

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