Preoperative Frailty and Chronic Pain After Cardiac Surgery: A Prospective Observational Study

A Prospective Observational Study

Britta C. Arends; Leon Timmerman; Lisette M. Vernooij; Lisa Verwijmeren; Douwe H. Biesma; Eric P. A. van Dongen; Peter G. Noordzij; Heleen J Blussé van Oud-Alblas


BMC Anesthesiol. 2022;22(201) 

In This Article


Study Population

Overall, 518 patients were included in the analysis. Reasons for exclusion were withdrawal (n = 9) or cancellation of surgery (n = 17). Fifty-seven patients (11%) had one or more missing values (see additional file Table A2 for characteristics of patients with and without missing data). Prior to surgery, 91 patients (18%) were considered frail and chronic pain was reported by 331 patients (64%) of whom 77 (23%) were frail. Of all patients with preexisting chronic pain, 13% (44/331) used one analgesic and 7% (22/331) used two or more analgesics. Most common analgesics were acetaminophen (28/331, 9%), NSAIDs (18/331, 5%) and opioids (16/331, 5%). Patients with chronic pain prior to surgery more often used an antidepressant, 26/331 versus 4/187 (8% versus 2%), compared to patients without chronic pain prior to surgery (p = 0.01). Additional file Table A3 demonstrates the baseline characteristics for patients with and without chronic pain prior to surgery.

Frailty and Chronic Pain After Cardiac Surgery

One hundred forty patients (27%) reported improvement of pain, 243 (47%) had no or unchanged pain and 135 patients (26%) reported new or worse chronic pain one year after surgery (Figure 1). According to our definition, chronic pain was present in 182 patients (35%), which included 47 patients with pre-existent moderate to severe pain that was not improved. Baseline characteristics according to chronic pain after cardiac surgery are presented in Table 1. Patients with chronic pain had higher EuroSCORE II at baseline, more often used opioids and had lower test results in the physical frailty domains. Patients preoperatively considered frail had a higher risk of developing postoperative chronic pain (aRR 1.58, 99% CI 1.08 – 2.30). Figure 2 demonstrates the association between each frailty domain and chronic pain one year after surgery. Medication use, living situation, mobility, gait speed, Nagi's physical functioning and preoperative HRQL were associated with chronic pain after surgery. Patients with preoperative excessive polypharmacy, patients who were living alone and patient with lower mental HRQL had increased risks to develop chronic pain (aRR 2.03, 99% CI 1.32 – 3.12, 1.54, 99% CI 1.11 – 2.13, and aRR 1.02 99% CI 1.01 – 1.03 per point decrease on mental HRQL, respectively). Also, preoperative impaired physical functioning was associated with postoperative chronic pain (aRR 1.11, 99% CI 1.04 – 1.18 per second increase on 5-MWT, aRR 1.06, 99% CI 1.02 – 1.10 per second increase on TGUG, aRR 1.32, 99% CI 1.19 – 1.46 per point increase on Nagi's scale and aRR 1.03 99% CI 1.01 – 1.05 per point decrease on physical HRQL). When patients with preexistent moderate to severe pain were excluded from the chronic pain definition in the post-hoc analysis, mobility and preoperative HRQL were no longer significantly associated (see figure in additional file 1 Figure A). Exclusion of patients who died within 12 months of follow-up did not change the associations (see figure in additional file Figure A2).

Figure 1.

Pain intensity before and one year after cardiac surgery. n: Number

Figure 2.

Adjusted relative risks for the development of chronic pain. aRR Adjusted relative risk, CI Confidence interval, MMSE Minimal mental state examination, MNA Mini-nutritional assessment, HRQL Health related quality of life. Polypharmacy was added as factor with polypharmacy defined as ≥ 5 and < 10 prescriptions and excessive polypharmacy defined as ≥ 10 prescriptions used. No polypharmacy was used as reference category. Log-binomial regression was used for statistical testing with correction for EuroSCORE II, intraoperative use of remifentanil, preexisting chronic pain and use of internal mammary artery. P-value ≤ 0.01 was considered statistically significant. #; per point decrease on physical and mental HRQL

Chronic Pain and Quality of Life at one Year After Surgery

Figure 3 demonstrates the mean change HRQL in all eight sub scores prior to and one year after surgery in patients with and without chronic pain. Patients without chronic pain significantly improved in each sub score, where patients with chronic pain worsened. Multivariable linear regression analysis demonstrated that patients with chronic pain reported worse physical HRQL one year after surgery compared to patients without chronic pain (β –10.37, 99% CI –12.57 – –8.17). Chronic pain was not associated with mental HRQL after one year (β –0.83, 99% CI – 3.26 – 1.60). Results were similar after excluding patients who were deceased within one year after surgery and also after the exclusion of patients with preexistent moderate to severe pain from the chronic pain definition.

Figure 3.

Change in health related quality of life in eight sub-scores.*p < 0.01, tested with Wilcoxon signed-rank test