title: Derivation and Validation of Prognosis-Based Age Cutoffs to Define Elderly in Cardiac Surgery.
abstract: The age cutoff to define elderly is controversial in cardiac surgery, empirically ranging from ≥65 to ≥80 years. Beyond semantics, this has important implications as a starting point for clinical care pathways and inclusion in trials. We sought to characterize the relationship between age and adverse outcomes in patients undergoing cardiac surgery and to derive and validate prognosis-based age cutoffs.
  
  
  
  Six thousand five hundred seventy one consecutive adult patients undergoing cardiac surgery at 3 hospitals in the United States and Canada were included in the cohort. Logistic regression models and generalized additive models with thin-plate splines were fit to the data. The age distribution was 50 to 59 years in 1244 (18.9%), 60 to 69 years in 2144 (32.6%), 70 to 79 years in 2000 (30.4%), ≥80 years in 1183 (18.0%) patients. After controlling for sex and type of operation, the relationship between age and 30-day operative mortality was found to be nonlinear. Receiver operating characteristic analysis showed that the optimal cutoffs to identify older patients at higher risk of operative mortality were greater than 74, 78, and 75 years for isolated coronary bypass, isolated valve surgery, and coronary bypass plus valve surgery, respectively. These age cutoffs were validated in an independent cohort.
  
  
  
  The relationship between age and operative mortality is not linear, manifesting a steeper rise after age 75 for coronary bypass and approaching octogenarian age for isolated valve surgery. Rather than using arbitrary age cutoffs to define elderly, the outcomes-based cutoff of ≥75 years should be used to identify the population of older adults that has higher risk and may benefit from preoperative geriatric evaluation and optimization.
authors.affiliation: From the Division of Cardiology, Department of Medicine, Jewish General Hospital, McGill University, Montreal, QC, Canada (J.A., L.G.R.); Department of Mathematics, McGill University, Montreal, QC, Canada (R.S.); Center for Clinical Epidemiology, Jewish General Hospital, McGill University, Montreal, QC, Canada (J.A., R.S.); Division of Cardiology, Department of Medicine, Beth Israel Deaconess Medical Center, Harvard University, Boston, MA (W.J.M.); Division of Cardiac Surgery, Department of Surgery, Beth Israel Deaconess Medical Center, Harvard University, Boston, MA (K.R.K.); Division of Cardiac Surgery, Department of Surgery, Jewish General Hospital, McGill University, Montreal, QC, Canada (Y.L., J.-F.M.); and Department of Cardiovascular Medicine, Massachusetts General Hospital, Harvard University, Boston (M.H.P.). jonathan.afilalo@mcgill.ca.
authors.forename: Jonathan
authors.initials: J
authors.lastname: Afilalo
authors.affiliation: From the Division of Cardiology, Department of Medicine, Jewish General Hospital, McGill University, Montreal, QC, Canada (J.A., L.G.R.); Department of Mathematics, McGill University, Montreal, QC, Canada (R.S.); Center for Clinical Epidemiology, Jewish General Hospital, McGill University, Montreal, QC, Canada (J.A., R.S.); Division of Cardiology, Department of Medicine, Beth Israel Deaconess Medical Center, Harvard University, Boston, MA (W.J.M.); Division of Cardiac Surgery, Department of Surgery, Beth Israel Deaconess Medical Center, Harvard University, Boston, MA (K.R.K.); Division of Cardiac Surgery, Department of Surgery, Jewish General Hospital, McGill University, Montreal, QC, Canada (Y.L., J.-F.M.); and Department of Cardiovascular Medicine, Massachusetts General Hospital, Harvard University, Boston (M.H.P.).
authors.forename: Russell
authors.initials: R
authors.lastname: Steele
authors.affiliation: From the Division of Cardiology, Department of Medicine, Jewish General Hospital, McGill University, Montreal, QC, Canada (J.A., L.G.R.); Department of Mathematics, McGill University, Montreal, QC, Canada (R.S.); Center for Clinical Epidemiology, Jewish General Hospital, McGill University, Montreal, QC, Canada (J.A., R.S.); Division of Cardiology, Department of Medicine, Beth Israel Deaconess Medical Center, Harvard University, Boston, MA (W.J.M.); Division of Cardiac Surgery, Department of Surgery, Beth Israel Deaconess Medical Center, Harvard University, Boston, MA (K.R.K.); Division of Cardiac Surgery, Department of Surgery, Jewish General Hospital, McGill University, Montreal, QC, Canada (Y.L., J.-F.M.); and Department of Cardiovascular Medicine, Massachusetts General Hospital, Harvard University, Boston (M.H.P.).
authors.forename: Warren J
authors.initials: WJ
authors.lastname: Manning
authors.affiliation: From the Division of Cardiology, Department of Medicine, Jewish General Hospital, McGill University, Montreal, QC, Canada (J.A., L.G.R.); Department of Mathematics, McGill University, Montreal, QC, Canada (R.S.); Center for Clinical Epidemiology, Jewish General Hospital, McGill University, Montreal, QC, Canada (J.A., R.S.); Division of Cardiology, Department of Medicine, Beth Israel Deaconess Medical Center, Harvard University, Boston, MA (W.J.M.); Division of Cardiac Surgery, Department of Surgery, Beth Israel Deaconess Medical Center, Harvard University, Boston, MA (K.R.K.); Division of Cardiac Surgery, Department of Surgery, Jewish General Hospital, McGill University, Montreal, QC, Canada (Y.L., J.-F.M.); and Department of Cardiovascular Medicine, Massachusetts General Hospital, Harvard University, Boston (M.H.P.).
authors.forename: Kamal R
authors.initials: KR
authors.lastname: Khabbaz
authors.affiliation: From the Division of Cardiology, Department of Medicine, Jewish General Hospital, McGill University, Montreal, QC, Canada (J.A., L.G.R.); Department of Mathematics, McGill University, Montreal, QC, Canada (R.S.); Center for Clinical Epidemiology, Jewish General Hospital, McGill University, Montreal, QC, Canada (J.A., R.S.); Division of Cardiology, Department of Medicine, Beth Israel Deaconess Medical Center, Harvard University, Boston, MA (W.J.M.); Division of Cardiac Surgery, Department of Surgery, Beth Israel Deaconess Medical Center, Harvard University, Boston, MA (K.R.K.); Division of Cardiac Surgery, Department of Surgery, Jewish General Hospital, McGill University, Montreal, QC, Canada (Y.L., J.-F.M.); and Department of Cardiovascular Medicine, Massachusetts General Hospital, Harvard University, Boston (M.H.P.).
authors.forename: Lawrence G
authors.initials: LG
authors.lastname: Rudski
authors.affiliation: From the Division of Cardiology, Department of Medicine, Jewish General Hospital, McGill University, Montreal, QC, Canada (J.A., L.G.R.); Department of Mathematics, McGill University, Montreal, QC, Canada (R.S.); Center for Clinical Epidemiology, Jewish General Hospital, McGill University, Montreal, QC, Canada (J.A., R.S.); Division of Cardiology, Department of Medicine, Beth Israel Deaconess Medical Center, Harvard University, Boston, MA (W.J.M.); Division of Cardiac Surgery, Department of Surgery, Beth Israel Deaconess Medical Center, Harvard University, Boston, MA (K.R.K.); Division of Cardiac Surgery, Department of Surgery, Jewish General Hospital, McGill University, Montreal, QC, Canada (Y.L., J.-F.M.); and Department of Cardiovascular Medicine, Massachusetts General Hospital, Harvard University, Boston (M.H.P.).
authors.forename: Yves
authors.initials: Y
authors.lastname: Langlois
authors.affiliation: From the Division of Cardiology, Department of Medicine, Jewish General Hospital, McGill University, Montreal, QC, Canada (J.A., L.G.R.); Department of Mathematics, McGill University, Montreal, QC, Canada (R.S.); Center for Clinical Epidemiology, Jewish General Hospital, McGill University, Montreal, QC, Canada (J.A., R.S.); Division of Cardiology, Department of Medicine, Beth Israel Deaconess Medical Center, Harvard University, Boston, MA (W.J.M.); Division of Cardiac Surgery, Department of Surgery, Beth Israel Deaconess Medical Center, Harvard University, Boston, MA (K.R.K.); Division of Cardiac Surgery, Department of Surgery, Jewish General Hospital, McGill University, Montreal, QC, Canada (Y.L., J.-F.M.); and Department of Cardiovascular Medicine, Massachusetts General Hospital, Harvard University, Boston (M.H.P.).
authors.forename: Jean-Francois
authors.initials: JF
authors.lastname: Morin
authors.affiliation: From the Division of Cardiology, Department of Medicine, Jewish General Hospital, McGill University, Montreal, QC, Canada (J.A., L.G.R.); Department of Mathematics, McGill University, Montreal, QC, Canada (R.S.); Center for Clinical Epidemiology, Jewish General Hospital, McGill University, Montreal, QC, Canada (J.A., R.S.); Division of Cardiology, Department of Medicine, Beth Israel Deaconess Medical Center, Harvard University, Boston, MA (W.J.M.); Division of Cardiac Surgery, Department of Surgery, Beth Israel Deaconess Medical Center, Harvard University, Boston, MA (K.R.K.); Division of Cardiac Surgery, Department of Surgery, Jewish General Hospital, McGill University, Montreal, QC, Canada (Y.L., J.-F.M.); and Department of Cardiovascular Medicine, Massachusetts General Hospital, Harvard University, Boston (M.H.P.).
authors.forename: Michael H
authors.initials: MH
authors.lastname: Picard
mesh_terms: D000367:Age Factors; D000368:Aged; D000369:Aged, 80 and over; D019540:Area Under Curve; D001900:Boston; D006348:Cardiac Surgical Procedures / Q000009:adverse effects / Q000401:mortality; D000066491:Clinical Decision-Making; D003661:Decision Support Techniques; D005260:Female; D015577:Geriatric Assessment; D006801:Humans; D053208:Kaplan-Meier Estimate; D016015:Logistic Models; D008297:Male; D008875:Middle Aged; D017711:Nonlinear Dynamics; D016017:Odds Ratio; D018579:Patient Selection; D011237:Predictive Value of Tests; D017064:Process Assessment, Health Care; D011792:Quebec; D012372:ROC Curve; D012042:Registries; D015203:Reproducibility of Results; D018570:Risk Assessment; D012307:Risk Factors; D016896:Treatment Outcome
keywords: aging; cardiac surgery; elderly; mortality; outcomes research