Cardiac Risk Stratification Strategy for Older Adults Undergoing Cancer Surgery

Advanced age should not exclude surgical interventions that can improve function, improve quality of life, or provide curative intent. However, careful screening of candidates is necessary to produce the best outcomes.1 Approximately 50% of Americans will have a surgical procedure after the age of 65 years.1 Postoperatively, some functional decline will occur in 31% of patients2 and greater than 20% may not be able to live independently after hospital discharge.3 Approximately 50% of older adults experience a complication related to hospitalization.4

Management of elderly patients with cancer who require a surgical procedure is challenging, with a greater risk for complications and mortality related to an increased incidence of cardiovascular, pulmonary, and renal disease. A decrease in physiologic reserves, multiple chronic conditions, and functional impairments are all associated with an increased risk for adverse surgical complications in patients with cancer.1-5 For the management of solid tumors, surgical removal provides the best curative opportunity. The International Society of Geriatric Oncology recommends a Comprehensive Geriatric Assessment (CGA) be completed on all patients older than 65 years who require surgical procedures.6

Ovarian Cancer

Three-quarters of women with ovarian cancer have advanced-stage disease and require treatment with extensive procedures, chemotherapy, and/or radiation. Almost half of patients with newly diagnosed ovarian cancer are 65 years or older.5 Older women derive the same cancer-related survival benefit from aggressive procedures for advanced-stage disease as younger women but have a higher risk for surgical morbidity and mortality.7 Older women are commonly excluded from clinical trials and are less likely to be offered surgical procedures for ovarian cancer, despite the evidence demonstrating feasibility in this age group. 8

The following 2 cases illustrate the importance of preoperative screening in women with ovarian cancer.

Case 1

GK is a 76-year-old woman who is scheduled for a cytoreductive procedure for advanced ovarian cancer. Her medical history includes hypertension (well controlled with an angiotensin receptor blocker), hypothyroidism (levothyroxine), and osteopenia (calcium 1200 mg/d and vitamin D). She lives with her partner of 50 years and enjoys salsa dancing weekly. She quit smoking 25 years ago. Review of her systems is negative except for an increased feeling of bloating and early satiety. Blood work and testing reveal an elevated creatinine level (1.3 mg/dL; normal range: 0.1-0.4 mg/dL), normal 12-lead electrocardiogram (ECG) with good R wave progression, and normal weight (body mass index [BMI] 24).

Case 2

MT is a 65-year-old woman who is scheduled for a cytoreductive procedure for advanced ovarian cancer. Her medical history includes diabetes (metformin discontinued, started insulin: recent hemoglobin A1c 9%), osteoarthritis, and poorly controlled hypertension. She walks her dog twice a day to the mailboxes in her community. Her daughter assists with independent activities of daily living. Review of systems is negative except for increased urination and bilateral knee pain. She has an elevated creatinine level (2.3 mg/dL), 12-lead ECG shows poor R wave progression possibly indicating left ventricular hypertrophy, and obese (BMI 35).

Risk Stratification

Risk stratification begins with a focused history and physical examination. Review of systems should explore potential cardiopulmonary prodromes such as dyspnea, palpitations, or near syncopal events accounting for the potential presentation in the older adult.9

Classification Systems

Several associations have collaborated to develop a classification system for preoperative assessment in older patients. The American College of Surgeons (ACS), American Society of

Anesthesiologists (ASA), and American Geriatrics Society (AGS)10,11 formed the ACS Geriatric Surgical Verification Program (GSV).12 The pilot project included enhancements to the original ACS National Surgical Quality Improvement Program (NSQIP) to include geriatric risk factors.13

The GSV Standard 5.6 Geriatric Vulnerability Screens Preoperative Assessment includes components of the CGA,13,14 which in some cases is more predictive of morbidity than the ASA Physical Status Classification System.15,16 GSV Standard 5.7 and 5.8 provide examples of management of high-risk vulnerable older adults and recommend interprofessional collaborations in cases of elective risk procedures (anesthesia, cardiology, physical therapy, pharmacy, social work, nutrition, and nursing). The ASA, using data from the NSQIP, applied a mixed effects model to sort elective noncardiac operations into low, intermediate, and high-risk categories. Examples of these procedures and their cardiac risk odds ratios are displayed in Table 1 17

TABLE 1. Examples of Elective Procedures and Cardiac Risk17

TABLE 2. Revised Cardiac Risk Index22,23

• High-risk surgical procedures (such as vascular and any open intraperitoneal or intrathoracic procedures)

• History of ischemic heart disease (myocardial infarction or positive exercise test, current complaint of chest pain considered to be secondary to myocardial ischemia, use of nitrates, or electrocardiogram with pathological Q waves not counting prior coronary revascularization procedure unless other criteria of ischemia are noted)

• History of congestive heart failure

• History of cerebrovascular disease

• Diabetes mellitus requiring treatment with insulin

• Preoperative serum creatinine >2.0 mg/dL

Rate

No risk factors: 0.4% (95% CI, 0.1-0.8)

1 risk factor: 1.0% (95% CI, 0.5-1.4)

2 risk factors: 2.4% (95% CI, 1.3-3.5)

3 or more risk factors: 5.4% (95% CI, 2.8-7.9)

TABLE 3. Comparison of Case Patients

Major adverse cardiac events (MACE) are a leading cause of mortality in noncardiac procedures.18 Patients older than 65 years of age account for nearly 73% of all cases of MACE in noncardiac procedures.19 Cardiac death is the first symptom in 50% of patients with heart disease.19,20 Multimorbidity is not sufficient to determine risk.21 The Revised Cardiac Risk Index (RCRI) uses 6 risk factors for prediction of cardiac risk for noncardiac procedures. It has also been used to stratify risk for noninvasive testing preoperatively (Table 2).22,23 The Geriatric-Sensitive Perioperative Cardiac Risk Index (GSCRI) contains 7 questions, including variables from the NSQIP geriatric subset, that when answered predicts the probability of perioperative myocardial infarction or cardiac arrest.24

Assessment of functional capacity should be used to guide risk assessment and aims to determine if the patient has the physiologic reserve capacity to undergo an operation without complication, which is most commonly estimated from the ability to perform activities of daily living expressed as metabolic equivalents (MET) of oxygen consumption. One MET (3.5 mL/kg/min) is equal to the resting oxygen consumption of a 40-year-old man weighing 70 kilograms.25 The Duke Activity Status Index (DASI) is a 12-item patient self-report questionnaire that measures functional capacity, aspects of quality of life, and estimates of peak oxygen uptake to assist in clinical decision-making.26 Over time, the DASI has been used to identify patients at increased risk for MACE during preoperative assessment with a point total of less than 34.27

Discussion

ASA

GK, who salsa dances with her partner, has significant aerobic activity and her high functional capacity is indicated in a DASI score of 50.2. With a normal BMI, her procedure can proceed initially as a laparoscopic procedure. Normal renal function and well-controlled blood pressure also add to her risk stratification. Overall cardiac risk for GK is low and she can proceed with the operation (Table 3).

ASA, American Society of Anesthesiologists; BSO, bilateral salpingo-oophorectomy; DASI, Duke Activity Status Index; GSCRI, Geriatric-Sensitive Perioperative Cardiac Risk Index; RCRI, Revised Cardiac Risk Index; TAH-BSO, total abdominal hysterectomy and bilateral salpingo-oophorectomy

MT has limited functional capacity due to osteoarthritis in her knees as indicated by a DASI score of 18.45. Her BMI is elevated requiring an open surgical procedure. Open procedures increase the risk for hospital mortality associated with MACE.28 Evidence of her poorly controlled diabetes and blood pressure further add to her risk. Renal insufficiency is a risk variable that is consistent across instruments. Poor R-wave progression is another common clinical finding and may reflect left ventricular hypertrophy possibly related to poorly controlled blood pressure or ventricular systolic or diastolic dysfunction, which can be elevated by a transthoracic echocardiogram.29

Considering the need for further cardiac evaluation, which may include nuclear testing with myocardial perfusion imaging, MT will require pharmacologic stress agents such as regadenoson or adenosine because of her inability to perform a stress test on a treadmill.30 With a history of obesity and other risk factors, MT is at high risk and may require a computed tomography (CT) coronary angiography or invasive coronary angiography with careful attention to her renal function.31 The Cardiac Comorbidity Risk Score (CCoR) tested in arthroplasty outperformed the RCRI.32

For the older adult requiring elective noncardiac surgery, a CGA along with careful assessment of function, type of surgery, and risk for major cardiovascular events aids in determination of risk stratification (Figure).6,33 The practical relevance of patient-reported outcome measures should have clinical and practical relevance.34 Identifying the limitations in functional reserves in the older adult leads to improved decision-making related to cardiac risk and elective procedures. ■

Cassandra Vonnes, DNP, GNP-BC,APRN, is the geriatric oncology Nurses Improving Care for Healthsystem Elders (NICHE) coordinator at Moffitt Cancer Center in Tampa, Florida. Dr Vonnes has taught clinical and didactic courses at the University of South Florida College of Nursing. Under her leadership, Moffitt Cancer Center was the first hospital in Florida to be recognized as Committed to Care Excellence for the Older Adult. In 2022, the Gerontological Advanced Practice Nurses Association awarded her the Excellence in Leadership 2022 Award.

References

1. Kim S, Brooks AK, Groban L. Preoperative assessment of the older surgical patient: honing in on geriatric syndromes. Clin Interv Aging. 2015;10:13-27.

2. Rønning B, Wyller TB, Jordhøy MS, et al. Frailty indicators and functional status in older patients after colorectal cancer surgery. J Geriatr Oncol. 2014;5(1):26-32.

3. van Abbema D, van Vuuren A, van den Berkmortel F, et al. Functional status decline in older patients with breast and colorectal cancer after cancer treatment: a prospective cohort study. J Geriatr Oncol. 2017;8(3):176-184.

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5. Tew WP. Ovarian cancer in the older woman. J Geriatr Oncol. 2016;7(5):354-361.

6. Wildiers H, Heeren P, Puts M, et al. International Society of Geriatric Oncology consensus on geriatric assessment in older patients with cancer. J Clin Oncol. 2014;32(24):2595-2603.

7. Langstraat C, Aletti GD, Cliby WA. Morbidity, mortality and overall survival in elderly women undergoing primary surgical debulking for ovarian cancer: a delicate balance requiring individualization. Gynecol Oncol. 2011;123(2):187-191.

8. Ferrero A, Fuso L, Tripodi E, et al. Ovarian cancer in elderly patients: patterns of care and treatment outcomes according to age and modified frailty index. Int J Gynecol Cancer. 2017;27(9):1863-1871.

9. Vonnes C, El-Rady R. When you hear hoof beats, look for the zebras: atypical presentation of illness in the older adult. J Nurse Pract. 2021;17(4):458-461.

ACC/AHA, American College of Cardiologists/American Heart Association; ASA, American Society of Anesthesiologists; DASI, Duke Activity Status Index; GSCRI, GeriatricSensitive Perioperative Cardiac Risk Index; MACE, major cardiovascular event; NSQIP, National Surgical Quality Improvement Program; RCRI, Revised Cardiac Risk Index

FIGURE . Noncardiac surgical risk determinants.

10. Chow WB, Rosenthal RA, Merkow RP, Ko CY, Esnaola NF. Optimal preoperative assessment of the geriatric surgical patient: a best practices guideline from the American College of Surgeons National Surgical Quality Improvement Program and the American Geriatrics Society. J Am Coll Surg. 2012;215(4):453-466.