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Ann Thorac Surg 2003;76:1604
© 2003 The Society of Thoracic Surgeons
a Cardiology and Health Services Research, Denver VA Medical Center, University of Colorado Health Sciences Center, 1055 Clermont St (111B), Denver, CO 80220, USA
e-mail: john.rumsfeld{at}med.va.gov
Numerous studies have demonstrated improvements in health-related quality of life (HRQL) following open-heart surgery. However, these are average improvements for populations of patients, and not all patients will derive a quality of life benefit from the operation. To date, we have had limited information on the proportion of patients that actually experience HRQL improvement with cardiac surgery, and about the factors predictive of who will (or will not) have HRQL gains.
The study by Falcoz and colleagues contributes to our understanding of HRQL outcomes following open-heart operations. Assessing changes in HRQL between pre-op and one-year after cardiac surgery in a cohort of 293 patients, they found average improvements in HRQL for the study population, consistent with previous studies. However, only 50% of the patients actually experienced a HRQL improvement. In other words, half the patients drove the overall HRQL improvement for the study population. Furthermore, they found that 36% of patients had "unsatisfactory" cardiac functional status at one year (ie patients still had limiting symptoms of angina or dyspnea), although their definition was quite strict. Finally, they found that preoperative HRQL measures were predictive of 1 year cardiac functional status, more so than clinical variables.
Further research is needed to confirm the results of this single-center investigation. However, this study carries the important, if sobering, message that a substantial proportion of patients undergoing cardiac surgery will not experience improvements in HRQL and/or will be left with cardiac functional limitation. This, in turn, strongly supports the need to further understand the determinants of HRQL outcomes following cardiac surgery, and then to develop interventions to improve HRQL outcomes. We routinely evaluate patients for mortality risk factors in order to identify the patients most likely to derive a survival benefit from the operation. Until we better understand the predictors of HRQL following cardiac surgery, our ability to risk-stratify patients with regard to HRQL outcomes, much less alter these outcomes, will remain limited.
In the meantime, it has previously been shown that preoperative HRQL independently predicts both mortality and postoperative HRQL after CABG surgery, and this study demonstrates the prognostic import of preoperative HRQL for cardiac functional status outcomes. Strong consideration should be given at this time to formal preoperative HRQL assessment to augment risk stratification with regard to a broad range of outcomes that are important from the patient's perspective.
Related Article
Ann. Thorac. Surg. 2003 76: 1598-1604.
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