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    "textoCompleto" => "<span class="elsevierStyleSections"><p id="par0005" class="elsevierStylePara elsevierViewall">Longer life expectancy and low birth rate in the western world has led to an inversion of the age pyramid&#46; The proportion of elderly patients undergoing cardiac surgery is therefore growing&#46;<a class="elsevierStyleCrossRef" href="#bib0045"><span class="elsevierStyleSup">1</span></a> In the United Kingdom&#44; the population of patients aged 90 years and over is expected to grow&#44; with life expectancy at this age predicted to be 4&#46;0 years for males and 4&#46;6 years for females&#46;<a class="elsevierStyleCrossRef" href="#bib0050"><span class="elsevierStyleSup">2</span></a> In the European Union &#40;EU&#41;&#44; in 2016&#44; there were 27&#46;3 million people aged 80 and over &#40;&#8220;elderly people&#8221;&#41; &#8211; seven million more than ten years ago&#46;<a class="elsevierStyleCrossRef" href="#bib0055"><span class="elsevierStyleSup">3</span></a> In the EU&#44; average life expectancy at the age of 80 stood at 9&#46;2 years in 2015&#46; In Portugal it was just below nine years&#44; while in Spain&#44; life expectancy at 80 years of age was an astonishing 9&#46;9 years&#46;<a class="elsevierStyleCrossRef" href="#bib0060"><span class="elsevierStyleSup">4</span></a></p><p id="par0010" class="elsevierStylePara elsevierViewall">For individual decision making&#44; age&#44; has therefore become less important&#44; compared to patient&#39;s co-morbidities and patient fitness&#46; Age-based cut-offs for the selection of aortic stenosis treatment method&#44; in the 2021 European Society of Cardiology&#39;s EACTS Valvular Heart Disease Guidelines&#44; have been the subject of controversy&#44; as trials were not based on age and life expectancy varies according to country&#46; In fact&#44; there is no compelling evidence indicating that older age should be an isolated criterion for the choice between transcatheter aortic valve replacement and surgical aortic valve replacement in otherwise low-risk patients&#46;<a class="elsevierStyleCrossRef" href="#bib0065"><span class="elsevierStyleSup">5</span></a></p><p id="par0015" class="elsevierStylePara elsevierViewall">Co-morbidities have been used to predict a variety of outcomes such as early mortality but also functional status&#44; quality of life&#44; complications and readmissions&#46; General prognostic tools&#44; such as the Charlson co-morbidity index&#44; assessing the impact on outcomes of associated conditions&#44; were followed by cardiac surgery specific risk scores&#46; The most frequently used is the EuroSCORE II&#44; which incorporates comorbidities such as extra cardiac arteriopathy&#44; renal dysfunction&#44; chronic obstructive pulmonary disorder&#44; neurological dysfunction&#44; insulin dependent diabetes&#44; but do not include frailty&#44; for the measurement of mortality risk and as a benchmark for the assessment of the quality of cardiac surgical services&#46; However&#44; patients show different vulnerability to external factors&#44; a condition referred to as the geriatric syndrome of frailty&#44; which is not included in any of the currently used risk scores&#46;</p><p id="par0020" class="elsevierStylePara elsevierViewall">Frail patients are vulnerable&#44; in the sense they are more susceptible to the complexity of a surgical process&#44; are at greater risk of complications after surgery&#44; and are less likely to recover function postoperatively&#46; Despite the consensus that frailty adds important information to preoperative risk assessment&#44; its measurement is challenging as demonstrated by the multiple instruments available&#46; Several of these frailty assessment tools are impractical or time consuming&#46;</p><p id="par0025" class="elsevierStylePara elsevierViewall">The Edmonton Frail Scale is a user friendly instrument for frailty assessment and includes the clock test for cognitive impairment and the &#8216;timed get up and go&#8217; for balance and mobility&#46; The other domains are mood&#44; functional independence&#44; medication use&#44; social support&#44; nutrition&#44; health attitudes&#44; continence&#44; burden of medical illness and quality of life&#46;<a class="elsevierStyleCrossRef" href="#bib0055"><span class="elsevierStyleSup">3</span></a> As this assessment is heavily influenced by cultural and language specificities&#44; there is a need for country specific validation&#46;</p><p id="par0030" class="elsevierStylePara elsevierViewall">In this issue of the Journal&#44; Castro et al&#46; assess the validity and reproducibility of the EFS Portuguese version&#46;<a class="elsevierStyleCrossRef" href="#bib0070"><span class="elsevierStyleSup">6</span></a> The authors are to be congratulated as they remind us of the importance of frailty assessment&#44; before clinical decision making&#44; validating a recognized tool in Portuguese&#46; Validity is defined by how well a measurement describes the phenomena of interest or whether two scales that measure or predict the same outcome are significantly correlated or result in concordant predictions&#46; It was assessed by evaluating the agreement with the Katz scale and Mini Mental State Examination&#44; Geriatric Depression Scale and Clinical Frailty Scale&#46; The methods and results sections are difficult to grasp by non-specialist readers of the Journal&#59; for example&#44; the difference between concepts of construct validity and criterion validity&#46; In this study&#44; although it seems that the Portuguese version of the EFS correlates with other indices measuring frailty&#44; we miss its predictive validity&#44; i&#46;e&#46;&#44; the ability of EFS to predict clinical outcomes&#46;</p><p id="par0035" class="elsevierStylePara elsevierViewall">Traditionally&#44; frailty was assessed by the &#8220;eyeball test&#8221;&#44; which might be of some value&#44; but is subjective and has low inter-rater validity&#46; Although there is no consensus on the ideal tool for frailty assessment&#44; there are currently several instruments that are both simple to apply and well correlated with negative outcomes&#46; For example&#44; slow preoperative gait speed was shown to predict a two to three-fold increased risk after cardiac surgery&#44; beyond traditional surgical risk scores&#46;<a class="elsevierStyleCrossRef" href="#bib0075"><span class="elsevierStyleSup">7</span></a> Similarly&#44; the Essential Frailty Toolset&#44; using a four item scale&#44; including lower-extremity weakness&#44; cognitive impairment&#44; anemia&#44; and hypoalbuminemia&#44; was a predictor of death and disability at one year after TAVR or SAVR&#46;<a class="elsevierStyleCrossRef" href="#bib0080"><span class="elsevierStyleSup">8</span></a></p><p id="par0040" class="elsevierStylePara elsevierViewall">In Santa Cruz Hospital&#44; our structured aortic stenosis heart team&#44; has been using pragmatic&#44; user friendly methods to assess frailty&#44; including instrumental activities of daily living&#44; gait speed&#44; lower-extremity muscle weakness and simplified cognitive assessment derived from the Mini Mental State Examination&#46;</p><p id="par0045" class="elsevierStylePara elsevierViewall">It would be interesting to prospectively apply this EFS version to a Portuguese population&#44; in terms of mortality&#44; stratified by EuroSCORE II&#47;STS score&#44; prediction of morbidity&#44; length of stay and late functional improvement&#44; for example&#44; in the interventional treatment of aortic stenosis&#44; as frailty is probably an important factor to consider in this setting&#46; This could provide evidence for risk assessment&#44; planning pre-intervention preparation&#47;rehabilitation and identification of futility&#46;</p><p id="par0050" class="elsevierStylePara elsevierViewall">Without question&#44; the incorporation of frailty should be part of a patient&#39;s evaluation&#44; enabling better informed discussion and shared decision making on interventional vs&#46; palliative care&#46; Also&#44; to identify and correct reversible frailty-related pre-intervention patient&#39;s deficits&#46;</p><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0005">Conflicts of interest</span><p id="par0055" class="elsevierStylePara elsevierViewall">The authors have no conflicts of interest to declare&#46;</p></span></span>"
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How to assess risk and counsel patients before cardiac surgery: Beyond an age cut-off
Como avaliar o risco e aconselhar os doentes antes da cirurgia cardíaca: para além de um limite de idade
Miguel Sousa Uvaa,
Autor para correspondência
migueluva@gmail.com

Corresponding author.
, Christopher Strongb, Pedro Magroa
a Department of Cardiac Surgery, Hospital Santa Cruz, Carnaxide, Portugal
b Department of Cardiology, Hospital Santa Cruz, Carnaxide, Portugal
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    "textoCompleto" => "<span class="elsevierStyleSections"><p id="par0005" class="elsevierStylePara elsevierViewall">Longer life expectancy and low birth rate in the western world has led to an inversion of the age pyramid&#46; The proportion of elderly patients undergoing cardiac surgery is therefore growing&#46;<a class="elsevierStyleCrossRef" href="#bib0045"><span class="elsevierStyleSup">1</span></a> In the United Kingdom&#44; the population of patients aged 90 years and over is expected to grow&#44; with life expectancy at this age predicted to be 4&#46;0 years for males and 4&#46;6 years for females&#46;<a class="elsevierStyleCrossRef" href="#bib0050"><span class="elsevierStyleSup">2</span></a> In the European Union &#40;EU&#41;&#44; in 2016&#44; there were 27&#46;3 million people aged 80 and over &#40;&#8220;elderly people&#8221;&#41; &#8211; seven million more than ten years ago&#46;<a class="elsevierStyleCrossRef" href="#bib0055"><span class="elsevierStyleSup">3</span></a> In the EU&#44; average life expectancy at the age of 80 stood at 9&#46;2 years in 2015&#46; In Portugal it was just below nine years&#44; while in Spain&#44; life expectancy at 80 years of age was an astonishing 9&#46;9 years&#46;<a class="elsevierStyleCrossRef" href="#bib0060"><span class="elsevierStyleSup">4</span></a></p><p id="par0010" class="elsevierStylePara elsevierViewall">For individual decision making&#44; age&#44; has therefore become less important&#44; compared to patient&#39;s co-morbidities and patient fitness&#46; Age-based cut-offs for the selection of aortic stenosis treatment method&#44; in the 2021 European Society of Cardiology&#39;s EACTS Valvular Heart Disease Guidelines&#44; have been the subject of controversy&#44; as trials were not based on age and life expectancy varies according to country&#46; In fact&#44; there is no compelling evidence indicating that older age should be an isolated criterion for the choice between transcatheter aortic valve replacement and surgical aortic valve replacement in otherwise low-risk patients&#46;<a class="elsevierStyleCrossRef" href="#bib0065"><span class="elsevierStyleSup">5</span></a></p><p id="par0015" class="elsevierStylePara elsevierViewall">Co-morbidities have been used to predict a variety of outcomes such as early mortality but also functional status&#44; quality of life&#44; complications and readmissions&#46; General prognostic tools&#44; such as the Charlson co-morbidity index&#44; assessing the impact on outcomes of associated conditions&#44; were followed by cardiac surgery specific risk scores&#46; The most frequently used is the EuroSCORE II&#44; which incorporates comorbidities such as extra cardiac arteriopathy&#44; renal dysfunction&#44; chronic obstructive pulmonary disorder&#44; neurological dysfunction&#44; insulin dependent diabetes&#44; but do not include frailty&#44; for the measurement of mortality risk and as a benchmark for the assessment of the quality of cardiac surgical services&#46; However&#44; patients show different vulnerability to external factors&#44; a condition referred to as the geriatric syndrome of frailty&#44; which is not included in any of the currently used risk scores&#46;</p><p id="par0020" class="elsevierStylePara elsevierViewall">Frail patients are vulnerable&#44; in the sense they are more susceptible to the complexity of a surgical process&#44; are at greater risk of complications after surgery&#44; and are less likely to recover function postoperatively&#46; Despite the consensus that frailty adds important information to preoperative risk assessment&#44; its measurement is challenging as demonstrated by the multiple instruments available&#46; Several of these frailty assessment tools are impractical or time consuming&#46;</p><p id="par0025" class="elsevierStylePara elsevierViewall">The Edmonton Frail Scale is a user friendly instrument for frailty assessment and includes the clock test for cognitive impairment and the &#8216;timed get up and go&#8217; for balance and mobility&#46; The other domains are mood&#44; functional independence&#44; medication use&#44; social support&#44; nutrition&#44; health attitudes&#44; continence&#44; burden of medical illness and quality of life&#46;<a class="elsevierStyleCrossRef" href="#bib0055"><span class="elsevierStyleSup">3</span></a> As this assessment is heavily influenced by cultural and language specificities&#44; there is a need for country specific validation&#46;</p><p id="par0030" class="elsevierStylePara elsevierViewall">In this issue of the Journal&#44; Castro et al&#46; assess the validity and reproducibility of the EFS Portuguese version&#46;<a class="elsevierStyleCrossRef" href="#bib0070"><span class="elsevierStyleSup">6</span></a> The authors are to be congratulated as they remind us of the importance of frailty assessment&#44; before clinical decision making&#44; validating a recognized tool in Portuguese&#46; Validity is defined by how well a measurement describes the phenomena of interest or whether two scales that measure or predict the same outcome are significantly correlated or result in concordant predictions&#46; It was assessed by evaluating the agreement with the Katz scale and Mini Mental State Examination&#44; Geriatric Depression Scale and Clinical Frailty Scale&#46; The methods and results sections are difficult to grasp by non-specialist readers of the Journal&#59; for example&#44; the difference between concepts of construct validity and criterion validity&#46; In this study&#44; although it seems that the Portuguese version of the EFS correlates with other indices measuring frailty&#44; we miss its predictive validity&#44; i&#46;e&#46;&#44; the ability of EFS to predict clinical outcomes&#46;</p><p id="par0035" class="elsevierStylePara elsevierViewall">Traditionally&#44; frailty was assessed by the &#8220;eyeball test&#8221;&#44; which might be of some value&#44; but is subjective and has low inter-rater validity&#46; Although there is no consensus on the ideal tool for frailty assessment&#44; there are currently several instruments that are both simple to apply and well correlated with negative outcomes&#46; For example&#44; slow preoperative gait speed was shown to predict a two to three-fold increased risk after cardiac surgery&#44; beyond traditional surgical risk scores&#46;<a class="elsevierStyleCrossRef" href="#bib0075"><span class="elsevierStyleSup">7</span></a> Similarly&#44; the Essential Frailty Toolset&#44; using a four item scale&#44; including lower-extremity weakness&#44; cognitive impairment&#44; anemia&#44; and hypoalbuminemia&#44; was a predictor of death and disability at one year after TAVR or SAVR&#46;<a class="elsevierStyleCrossRef" href="#bib0080"><span class="elsevierStyleSup">8</span></a></p><p id="par0040" class="elsevierStylePara elsevierViewall">In Santa Cruz Hospital&#44; our structured aortic stenosis heart team&#44; has been using pragmatic&#44; user friendly methods to assess frailty&#44; including instrumental activities of daily living&#44; gait speed&#44; lower-extremity muscle weakness and simplified cognitive assessment derived from the Mini Mental State Examination&#46;</p><p id="par0045" class="elsevierStylePara elsevierViewall">It would be interesting to prospectively apply this EFS version to a Portuguese population&#44; in terms of mortality&#44; stratified by EuroSCORE II&#47;STS score&#44; prediction of morbidity&#44; length of stay and late functional improvement&#44; for example&#44; in the interventional treatment of aortic stenosis&#44; as frailty is probably an important factor to consider in this setting&#46; This could provide evidence for risk assessment&#44; planning pre-intervention preparation&#47;rehabilitation and identification of futility&#46;</p><p id="par0050" class="elsevierStylePara elsevierViewall">Without question&#44; the incorporation of frailty should be part of a patient&#39;s evaluation&#44; enabling better informed discussion and shared decision making on interventional vs&#46; palliative care&#46; Also&#44; to identify and correct reversible frailty-related pre-intervention patient&#39;s deficits&#46;</p><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0005">Conflicts of interest</span><p id="par0055" class="elsevierStylePara elsevierViewall">The authors have no conflicts of interest to declare&#46;</p></span></span>"
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