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Ann Thorac Surg 2002;73:1228
© 2002 The Society of Thoracic Surgeons
a 2D4.37 Walter MacKenzie Health Sciences Center, University of Alberta Hospital, Edmonton, Alberta, Canada T6G 2B7
e-mail: dbross{at}cha.ab.ca
This manuscript by Dr Falcoz and associates seeks to address an important but often overlooked area of assessment of cardiac surgical results. How our patients perceive the success of our operations in benefiting their lives is seldom included in cardiac surgical publications, which traditionally rely on the more easily determined endpoints of death and obvious morbidity. In the present article the authors add to their previous contributions by comparing two well validated but generic quality of life assessment instruments; the Nottingham Health Profile (NHP) and the Short Form Health Survey (SF36). Although both have been used before to evaluate quality of life following cardiac surgery, neither was specifically designed for this purpose. Both are simple to administer, take about 13 minutes to complete, and are acceptable to patients. Overall the authors found that the SF36 was more sensitive to change, better reflected the true clinical picture, and did not suffer from the ceiling effect observed with the NHP.
Why should cardiac surgeons care about properly measuring patient quality of life data and why is this paper important? As rates for mortality and major, catastrophic morbidity such as stroke fall to the low single digits (as is the case for the majority of patients undergoing cardiac surgery), using these traditional indices of success becomes less useful. Validated tools such as the SF36 may be one of the few scientific ways, along with cost data, to demonstrate the superiority of procedures such as off-pump versus on-pump coronary bypass, coronary bypass versus repeat percutaneous transluminal coronary angioplasty and stenting, etc, when the mortality of each technique is 2% or less. At the other end of the spectrum where operative mortality or morbidity is potentially high (eg, mitral valve repair for ischemic cardiomyopathy) cardiac surgeons must be prepared to demonstrate that their procedures are effective in significantly improving quality of life to justify interventions.
Moreover, there are some intriguing recent data, which suggest that these simple, safe and inexpensive tests may offer much more important information than most surgeons would have expected to find. In an article published in JAMA, Rumsfield and colleagues [1] found that the preoperative Physical Component Summary of the SF36 was a statistically significant predictor of six month mortality for coronary artery bypass patients, even after adjustment for known risk factors. A 10 point lower score predicted a 39% increased risk for mortality at six months. This was greater than the risk associated with an elevated preoperative serum creatinine or smoking. In a previous publication [2], the present authors found that most components of the Nottingham Health Profile returned to normal three years after cardiac surgery. However, sleep disturbances did not and persisted even after three years. This suggests the possibility that subtle brain injury from cardiopulmonary bypass could be responsible. Surgeons eager to demonstrate that off-pump coronary artery bypass grafting is advantageous are well advised to look at these tests as they may offer a simple means to evaluate clinically important sequelae of cardiac surgery.
Doctor Falcoz and associates are to be congratulated on persevering in their investigations of this area. The rest of the cardiac surgery community would be wise to carefully study their results.
References
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