Frailty is independently associated with short-term outcomes for elderly patients with non-ST-segment elevation myocardial infarction

The impact of patient-reported frailty on cardiovascular outcomes in elderly patients after non-ST-acute coronary syndrome

BACKGROUND

As life expectancy increases, the population of older individuals with coronary artery disease and frailty is growing. We aimed to assess the impact of patient-reported frailty on the treatment and prognosis of elderly early survivors of non-ST-elevation acute coronary syndrome (NSTE-ACS).

METHODS

Frailty data were obtained from two prospective trials, POPular Age and the POPular Age Registry, which both assessed elderly NSTE-ACS patients. Frailty was assessed one month after admission with the Groningen Frailty Indicator (GFI) and was defined as a GFI-score of 4 or higher. In these early survivors of NSTE-ACS, we assessed differences in treatment and 1-year outcomes between frail and non-frail patients, considering major adverse cardiovascular events (MACE, including cardiovascular mortality, myocardial infarction, and stroke) and major bleeding.

RESULTS

The total study population consisted of 2192 NSTE-ACS patients, aged ≥70 years. The GFI-score was available in 1320 patients (79 ± 5 years, 37% women), of whom 712 (54%) were considered frail. Frail patients were at higher risk for MACE than non-frail patients (9.7% vs. 5.1%, adjusted hazard ratio [HR] 1.57, 95% confidence interval [CI] 1.01-2.43, p = 0.04), but not for major bleeding (3.7% vs. 2.8%, adjusted HR 1.23, 95% CI 0.65-2.32, p = 0.53). Cubic spline analysis showed a gradual increase of the risk for clinical outcomes with higher GFI-scores.

CONCLUSIONS

In elderly NSTE-ACS patients who survived 1-month follow-up, patient-reported frailty was independently associated with a higher risk for 1-year MACE, but not with major bleeding. These findings emphasize the importance of frailty screening for risk stratification in elderly NSTE-ACS patients.

Invasive vs. conservative management of older patients with non-ST-elevation acute coronary syndrome: individual patient data meta-analysis

BACKGROUND AND AIMS

Older patients with non-ST-elevation acute coronary syndrome (NSTEACS) are less likely to receive guideline-recommended care including coronary angiography and revascularization. Evidence-based recommendations regarding interventional management strategies in this patient cohort are scarce. This meta-analysis aimed to assess the impact of routine invasive vs. conservative management of NSTEACS by using individual patient data (IPD) from all available randomized controlled trials (RCTs) including older patients.

METHODS

MEDLINE, Web of Science and Scopus were searched between 1 January 2010 and 11 September 2023. RCTs investigating routine invasive and conservative strategies in persons >70 years old with NSTEACS were included. Observational studies or trials involving populations outside the target range were excluded. The primary endpoint was a composite of all-cause mortality and myocardial infarction (MI) at 1 year. One-stage IPD meta-analyses were adopted by use of random-effects and fixed-effect Cox models. This meta-analysis is registered with PROSPERO (CRD42023379819).

RESULTS

Six eligible studies were identified including 1479 participants. The primary endpoint occurred in 181 of 736 (24.5%) participants in the invasive management group compared with 215 of 743 (28.9%) participants in the conservative management group with a hazard ratio (HR) from random-effects model of 0.87 (95% CI 0.63-1.22; P = .43). The hazard for MI at 1 year was significantly lower in the invasive group compared with the conservative group (HR from random-effects model 0.62, 95% CI 0.44-0.87; P = .006). Similar results were seen for urgent revascularization (HR from random-effects model 0.41, 95% CI 0.18-0.95; P = .037). There was no significant difference in mortality.

CONCLUSIONS

No evidence was found that routine invasive treatment for NSTEACS in older patients reduces the risk of a composite of all-cause mortality and MI within 1 year compared with conservative management. However, there is convincing evidence that invasive treatment significantly lowers the risk of repeat MI or urgent revascularisation. Further evidence is needed from ongoing larger clinical trials.

Cancer history and physical function in patients with cardiovascular disease

Both cancer and cardiovascular disease (CVD) cause skeletal muscle mass loss, thereby increasing the likelihood of a poor prognosis. We investigated the association between cancer history and physical function and their combined association with prognosis in patients with CVD. We retrospectively reviewed 3,796 patients with CVD (median age: 70 years; interquartile range [IQR]: 61-77 years) who had undergone physical function tests (gait speed and 6-minute walk distance [6MWD]) at discharge. We performed multiple linear regression analyses to assess potential associations between cancer history and physical function. Moreover, Kaplan-Meier curves and Cox regression analyses were used to evaluate prognostic associations in four groups of patients categorized by the absence or presence of cancer history and of high or low physical function. Multiple regression analyses showed that cancer history was significantly and independently associated with a lower gait speed and 6MWD performance. A total of 610 deaths occurred during the follow-up period (median: 3.1 years; IQR: 1.4-5.4 years). The coexistence of low physical function and cancer history in patients with CVD was associated with a significantly higher mortality risk, even after adjusting for covariates (cancer history/low gait speed, hazard ratio [HR]: 1.93, P < 0.001; and cancer history/low 6MWD, HR: 1.61, P = 0.002). Cancer history is associated with low physical function in patients with CVD, and the combination of both factors is associated with a poor prognosis.

Prevalence of frailty according to the Hospital Frailty Risk Score and related factors in older patients with acute coronary syndromes in Vietnam

OBJECTIVES

(1) To investigate the prevalence of frailty defined by the Hospital Frailty Risk Score (HFRS), a new scale for assessing frailty, in older patients with acute coronary syndrome (ACS); (2) To identify associations between frailty and the prescriptions of cardiovascular medications, percutaneous coronary intervention (PCI) and in-hospital adverse outcomes.

METHODS

An observational study was conducted in patients aged older than 60 years with ACS at Thong Nhat Hospital from August to December 2022. The Hospital Frailty Risk Score is retrospectively calculated for all participants based on ICD-10 codes, and those with HFRS scores ≥5 were defined as frail. Logistic regression models were applied to examine the relationship between frailty and the study outcomes.

RESULTS

There were 511 participants in the study. The median age was 72.7, 60% were male and 29% were frail. Frailty was associated with lower odds of beta-blocker use at admission (OR .49 95% CI .25-.94), treatment with PCI during hospitalisation (OR .48, 95% CI .30-.75), but did not show an association with prescriptions of cardiovascular drugs at discharge. Frailty was significantly associated with increased odds of adverse outcomes, including major bleeding (OR 4.07, 95% CI1.73-9.54), hospital-acquired pneumonia (OR 2.55, 95% CI 1.20-5.42), all-cause in-hospital mortality (OR 3.14, 95% CI 1.37-7.20) and non-cardiovascular in-hospital mortality (OR 10.73, 95% CI 1.93-59.55).

CONCLUSIONS

The HFRS was an effective tool for stratifying frailty and predicting adverse health outcomes in older patients with ACS. Further research is needed to compare the HFRS with other frailty assessment tools in this population.

Spectrum of Ischemic Heart Disease Throughout a Woman's Life Cycle

Ischemic heart disease (IHD) is the leading cause of morbidity and mortality in both genders; however, young women fare the worst, likely reflecting the more complex spectrum of IHD in women when compared to men. Substantial sex-based differences exist in the underlying risk factors, risk enhancers, presentation, diagnosis, and pathophysiology of IHD that are mainly attributed to the influence of female sex hormones. This article reviews the spectrum of IHD including obstructive epicardial coronary artery disease (CAD), myocardial infarction with no obstructive coronary artery disease, ischemia with no obstructive coronary artery disease, spontaneous coronary artery dissection, coronary microvascular dysfunction, vasospastic angina, and coronary thrombosis/embolism that occur in women throughout various stages of their life cycle. We aim to update clinicians on the diagnosis and management of these various types of IHD and highlight where further randomized controlled studies are needed to determine optimal treatment and inform guideline-directed medical therapy.

Relationship between the lymphocyte to C‑reactive protein ratio and coronary artery disease severity

Coronary atherosclerosis is a chronic systemic inflammatory disease. Laboratory parameters such as the neutrophil-to-lymphocyte ratio (NLR), platelet-to-lymphocyte ratio (PLR) and systemic immune inflammation index (SII) have been used to assess inflammation degree and coronary artery disease (CAD) severity. The lymphocyte-to-C-reactive protein ratio (LCR) is a new SII. However, its relationship with CAD development and severity is unclear. A total of 1,107 patients (479 in control group, 628 in CAD group) underwent coronary angiography. The routine and biochemical indices of the venous blood of patients were assessed before coronary angiography. LCR, SII, NLR and PLR were calculated and statistical analyses were performed. Propensity score matching (PSM) and a logistic regression model were used to analyze the relationship between LCR and CAD. After the PSM, 384 pairs of patients with or without CAD were successfully matched. After the median binary classification of all indicators, uni- and multivariate logistic regression analyses showed that platelet count was an independent risk factor and LCR was an independent protective factor. Using the same method, in the coronary heart disease severity group, 212 pairs were successfully matched and NLR and PLR were independent risk factors, while LCR was an independent protective factor. In conclusion, LCR is an independent protective factor against CAD development and severity.

Cross-cultural adaption and inter-rater reliability of the Swedish version of the updated clinical frailty scale 2.0

BACKGROUND

Worldwide, there is a large and growing group of older adults. Frailty is known as an important discriminatory factor for poor outcomes. The Clinical Frailty Scale (CFS) has become a frequently used frailty instrument in different clinical settings and health care sectors, and it has shown good predictive validity. The aims of this study were to describe and validate the translation and cultural adaptation of the CFS into Swedish (CFS-SWE), and to test the inter-rater reliability (IRR) for registered nurses using the CFS-SWE.

METHODS

An observational study design was employed. The ISPOR principles were used for the translation, linguistic validation and cultural adaptation of the scale. To test the IRR, 12 participants were asked to rate 10 clinical case vignettes using the CFS-SWE. The IRR was assessed using intraclass correlation and Krippendorff's alpha agreement coefficient test.

RESULTS

The Clinical Frailty Scale was translated and culturally adapted into Swedish and is presented in its final form. The IRR for all raters, measured by an intraclass correlation test, resulted in an absolute agreement value among the raters of 0.969 (95% CI: 0.929-0.991) and a consistency value of 0.979 (95% CI: 0.953-0.994), which indicates excellent reliability. Krippendorff's alpha agreement coefficient for all raters was 0.969 (95% CI: 0.917-0.988), indicating near-perfect agreement. The sensitivity of the reliability was examined by separately testing the IRR of the group of specialised registered nurses and non-specialised registered nurses respectively, with consistent and similar results.

CONCLUSION

The Clinical Frailty Scale was translated, linguistically validated and culturally adapted into Swedish following a well-established standard technique. The IRR was excellent, judged by two established, separately used, reliability tests. The reliability test results did not differ between non-specialised and specialised registered nurses. However, the use of case vignettes might reduce the generalisability of the reliability findings to real-life settings. The CFS has the potential to be a common reference tool, especially when older adults are treated and rehabilitated in different care sectors.

Effect of Frailty on the Long-Term Prognosis of Elderly Patients with Acute Myocardial Infarction

Background

To investigate the effect of frailty on the long-term prognosis of elderly patients with acute myocardial infarction (AMI).

Methods

The data of 238 AMI patients (aged ≥75 years) were retrospectively reviewed. They were divided into two groups according to the Modified Frailty Index (mFI): frailty group (mFI≥0.27, n=143) and non-frailty group (mFI<0.27, n=95). The major adverse cardiovascular and cerebrovascular events (MACEs) and Kaplan-Meier survival curves of the two groups were compared. Multivariate Cox regression analysis was used to identify the risk factors for MACEs.

Results

The frailty group showed a significantly older age as well as a higher N-terminal proB-type natriuretic peptide level, Global Registry of Acute Coronary Events score, and CRUSADE bleeding score compared with the non-frailty group (P<0.05). A significantly greater proportion of patients with combined heart failure, atrial fibrillation, comorbidity, and activities of daily living score of <60 was also observed in the frailty group compared with the non-frailty group (P<0.05). At 36 months after AMI, the frailty group vs the non-frailty group showed a significantly poorer survival (log-rank P=0.005), higher incidence of MACEs (50.35 vs 29.47, P=0.001), higher overall mortality rate (20.98% vs 7.37%, P=0.006), higher 30-day mortality rate (13.99% vs 5.26%, P=0.033), higher major bleeding rate (14.69% vs 5.26, P=0.018), and lower repeat revascularization rate (2.10% vs 8.42%, P=0.03). Frailty, type 2 diabetes, and N-terminal proB-type natriuretic peptide ≥1800 pg/mL were independent risk factors for MACEs.

Conclusion

Frailty is an independent risk factor affecting the long-term prognosis of elderly patients with AMI.

Guideline concordant prescribing following myocardial infarction in people who are frail: A systematic review

AIMS

The risk-to-benefit ratio of cardioprotective medications in frail older adults is uncertain. The objective was to systematically review prescribing of guideline-recommended cardioprotective medications following myocardial infarction (MI) in people who are frail.

DATA SOURCES

Ovid Medline, PubMed and Cochrane were searched from inception to October 2022 for studies that reported prescribing of one or more cardioprotective medication classes post-MI or acute coronary syndromes in people with frailty.

STUDY SELECTION

We included observational studies that reported prescribing of cardioprotective medications post-MI stratified by frailty status.

RESULTS

Overall, 16 cohort studies published from 2013 to 2022 that used seven different frailty scales were included. Prescribing of all cardioprotective medication classes following MI was lower in frail compared to non-frail people, with absolute rates of prescribing varying substantially across studies. Median prescribing in frail and non-frail people, respectively, was 88.9% (IQR 81.5-96.2) and 93.1% (IQR 92.0-98.9) for aspirin; 68.1% (IQR 61.9-91.2) and 86.7% (IQR 79.5-92.8) for P2Y12-inhibitors; 83.1% (IQR 76.9-91.3) and 94.0% (IQR 87.1-95.9) for lipid-lowering therapy; 67.9% (IQR 60.6-74.0) and 74.7% (IQR 71.3-84.5) for angiotensin-converting enzyme inhibitor/angiotensin II receptor blockers; and 74.1% (IQR 69.2-79) and 77.6% (IQR 71.8-85.9) for beta-blockers.

CONCLUSION

People who were frail were less likely to be prescribed guideline recommended medication classes post-MI than those who were non-frail. Further research is needed into treatment benefits and risks in frail people to avoid unnecessarily withholding treatment in this high-risk population, while also minimising potential for medication related harm.

Interrater reliability of the Clinical Frailty Scale in the anesthesia preadmission clinic

PURPOSE

As many as 30% of patients with frailty die, are discharged to a nursing home, or have a new disability after surgery. The 2010 United Kingdom National Confidential Enquiry into Patient Outcome and Death recommended that frailty assessment be developed and included in the routine risk assessment of older surgical patients. The Clinical Frailty Scale (CFS) is a simple, clinically-assessed frailty measure; however, few studies have investigated interrater reliability of the CFS in the surgical setting. The objective of this study was to determine the interrater reliability of frailty classification between anesthesiologists and perioperative nurses.

METHODS

We conducted a cohort study assessing interrater reliability of the CFS between perioperative nurses and anesthesiologists for elective surgical patients aged ≥ 65 yr, admitted to a large regional university-affiliated hospital in Australia between July 2020 and February 2021. Agreement was measured via Cohen's kappa.

RESULTS

Frailty assessment was conducted on 238 patients with a median [interquartile range] age of 74 [70-80] yr. Agreement was perfect between nursing and medical staff for CFS scores in 112 (47%) patients, with a further 99 (42%) differing by only one point. Interrater kappa was 0.70 (95% confidence interval, 0.63 to 0.77; P < 0.001), suggesting good agreement between anesthesiologists and perioperative nurses.

CONCLUSION

This study suggests that CFS assessment by either anesthesiologists or nursing staff is reliable across a population of patients from a range of surgical specialities, with an acceptable degree of agreement. The CFS measurement should be included in the normal preanesthesia clinic workflow.

Predictive Biochemical Model of Frailty and Mortality After Acute Myocardial Infarction

Frailty, characterized by reduced resistance to stressors, is associated with adverse outcomes in patients with myocardial infarction. The Fried score is commonly used to assess frailty but has several limitations. This study aimed to evaluate the relation between frailty and blood biomarkers and their predictive value for long-term mortality using a biochemical model. A total of 2 cohorts of elderly patients (>65 years old) hospitalized for acute coronary syndrome were included. Geriatric assessments and several blood biomarkers were measured. The predictive models for frailty were developed using logistic regression. The survival models were also developed using Cox regression. Among 466 patients, 9 biomarkers were significantly associated with frailty. Between these biomarkers, white blood cells count, hemoglobin, and fibrinogen showed the highest predictive power. Model 1, without growth differentiation factor 15 (GDF-15), showed a better accuracy in predicting the mortality than the Fried score. Model 2, with GDF-15, had a stronger correlation with frailty but had a lower predictive power for survival. Frailty is associated with dysregulation in the physiological systems and several biomarkers were linked to this fact in our study. However, the inclusion of GDF-15 did not significantly improve the model's predictive ability. Frailty assessment using blood biomarkers can provide valuable prognostic information in elderly patients with acute coronary syndrome.

Discordance in Frailty Measures in Old Community Dwelling People with Multimorbidity - A Cross-Sectional Study

Purpose

Assessment of frailty is a key method to identify older people in need of holistic care. However, agreement between different frailty instrument varies. Thus, groups classified as frail by different instruments are not completely overlapping. This study evaluated differences in sociodemographic factors, cognition, functional status, and quality of life between older persons with multimorbidity who were discordantly classified by five different frailty instruments, with focus on the Clinical Frailty Scale (CFS) and Fried's Frailty Phenotype (FP).

Participants and Methods

This was a cross-sectional study in a community-dwelling setting. Inclusion criteria were as follows: ≥75 years old, ≥3 visits to the emergency department the past 18 months, and ≥3 diagnoses according to ICD-10. 450 participants were included. Frailty was assessed by CFS, FP, Short Physical Performance Battery (SPPB), Grip Strength and Walking Speed.

Results

385 participants had data on all frailty instruments. Prevalence of frailty ranged from 34% (CFS) to 75% (SPPB). Nine percent of participants were non-frail by all instruments, 20% were frail by all instruments and 71% had discordant frailty classifications. Those who were frail according to CFS but not by the other instruments had lower cognition and functional status. Those who were frail according to FP but not CFS were, to a larger extent, women, lived alone, had higher cognitive ability and functional status.

Conclusion

The CFS might not identify physically frail women in older community-dwelling people with multimorbidity. They could thus be at risk of not be given the attention their frail condition need.

Management of Coronary Artery Disease in Older Adults: Recent Advances and Gaps in Evidence

Coronary artery disease (CAD) is highly prevalent in older adults, yet its management remains challenging. Treatment choices are made complex by the frailty burden of older patients, a high prevalence of comorbidities and body composition abnormalities (e.g., sarcopenia), the complexity of coronary anatomy, and the frequent presence of multivessel disease, as well as the coexistence of major ischemic and bleeding risk factors. Recent randomized clinical trials and epidemiological studies have provided new data on optimal management of complex patients with CAD. However, frail older adults are still underrepresented in the literature. This narrative review aims to highlight the importance of assessing frailty as an aid to guide therapeutic decision-making and tailor CAD management to the specific needs of older adults, taking into account age-related pharmacokinetic and pharmacodynamic changes, polypharmacy, and potential drug interactions. We also discuss gaps in the evidence and offer perspectives on how best in the future to optimize the global strategy of CAD management in older adults.

Association Between Claims-Defined Frailty and Outcomes Following 30 Versus 12 Months of Dual Antiplatelet Therapy After Percutaneous Coronary Intervention: Findings From the EXTEND-DAPT Study

Background Frailty is rarely assessed in clinical trials of patients who receive dual antiplatelet therapy (DAPT) after percutaneous coronary intervention. This study investigated whether frailty defined using claims data is associated with outcomes following percutaneous coronary intervention, and if there is a differential association in patients receiving standard versus extended duration DAPT. Methods and Results Patients ≥65 years of age in the DAPT (Dual Antiplatelet Therapy) Study, a randomized trial comparing 30 versus 12 months of DAPT following percutaneous coronary intervention, had data linked to Medicare claims (n=1326), and a previously validated claims-based index was used to define frailty. Net adverse clinical events, a composite of all-cause mortality, myocardial infarction, stroke, and major bleeding, were compared between frail and nonfrail patients. Patients defined as frail using claims data (12.0% of the cohort) had higher incidence of net adverse clinical events (23.1%) compared with nonfrail patients (10.7%; P<0.001) at 18-month follow-up and increased risk after multivariable adjustment (adjusted hazard ratio [HR], 2.24 [95% CI, 1.38-3.63]). There were no differences in effects of extended duration DAPT on net adverse clinical events for frail (HR, 1.42 [95% CI, 0.73-2.75]) and nonfrail patients (HR, 1.18 [95% CI, 0.83-1.68]; interaction P=0.61), although analyses were underpowered. Bleeding was highest among frail patients who received extended duration DAPT. Conclusions Among older patients in the DAPT Study, claims-defined frailty was associated with higher net adverse clinical events. Effects of extended duration DAPT were not different for frail patients, although comparisons were underpowered. Further investigation of how frailty influences ischemic and bleeding risks with DAPT are warranted. Registration URL: https://www.clinicaltrials.gov; Unique identifier: NCT00977938.

Frailty, Treatments, and Outcomes in Older Patients With Myocardial Infarction: A Nationwide Registry-Based Study

Background Guidelines recommend that patients with myocardial infarction (MI) receive equal care regardless of age. However, withholding treatment may be justified in elderly and frail patients. This study aimed to investigate trends in treatments and outcomes of older patients with MI according to frailty. Methods and Results All patients aged ≥75 years with first-time MI during 2002 to 2021 were identified through Danish nationwide registries. Frailty was categorized using the Hospital Frailty Risk Score. One-year risk and hazard ratios (HRs) for days 0 to 28 and 29 to 365 were calculated for all-cause death. A total of 51 022 patients with MI were included (median, 82 years; 50.2% women). Intermediate/high frailty increased from 26.7% in 2002 to 2006 to 37.1% in 2017 to 2021. Use of treatment increased substantially regardless of frailty: for example, 28.1% to 48.0% (statins), 21.8% to 33.7% (dual antiplatelet therapy), and 7.6% to 28.0% (percutaneous coronary intervention) for high frailty (all P-trend <0.001). One-year death decreased for low frailty (35.1%-17.9%), intermediate frailty (49.8%-31.0%), and high frailty (62.8%-45.6%), all P-trend <0.001. Age- and sex-adjusted 29- to 365-day HRs (2017-2021 versus 2002-2006) were 0.53 (0.48-0.59), 0.62 (0.55-0.70), and 0.62 (0.46-0.83) for low, intermediate, and high frailty, respectively (P-interaction=0.23). When additionally adjusted for treatment, HRs attenuated to 0.74 (0.67-0.83), 0.83 (0.74-0.94), and 0.78 (0.58-1.05), respectively, indicating that increased use of treatment may account partially for the observed improvements. Conclusions Use of guideline-based treatments and outcomes improved concomitantly in older patients with MI, irrespective of frailty. These results indicate that guideline-based management of MI may be reasonable in the elderly and frail.

The Frail Scale - A Risk Stratification in Older Patients with Acute Coronary Syndrome

Purpose

The aim of this study was to explore the impact of frailty on in-hospital adverse outcomes and net adverse clinical events (NACE) in older patients with acute coronary syndrome.

Patients and Methods

This observational study included elderly patients (≥60 years old), diagnosed with acute coronary syndrome (ACS) at admission from February 2021 to August 2021. The primary outcome was net adverse clinical events (NACE) defined as a composite of all-cause mortality, stroke, and major bleeding. Secondary outcome was in-hospital adverse outcomes including arrhythmia, acquired pneumonia, stroke, major bleeding, and all-cause mortality. Frailty was assessed using the Frail scale (FS). Data about socio-demographics, comorbidities, body mass index, ACS type, coronary angiography, left ventricular ejection fraction, and length of hospital stay were also collected. Univariate and multivariate logistic regressions were employed to identify the potential association between frailty and outcomes.

Results

Of the 116 ACS patients, 38 patients were frail (32.76%). Frail subjects were more often female (50%) and older (p < 0.01) and had higher rates of in-hospital adverse outcomes (OR = 2.37, p = 0.05) and NACE (OR = 7.12; p < 0.01). In univariate analysis, the increased frail score was significantly associated with increased odds of NACE (unadjusted OR = 1.98, 95% CI 1.17-3.35 for each score increase in Frail Score). In multivariable logistic regression, models controlling for age, gender, PCI, LVEF, and coronary angiography (adjusted OR 2.19, 95% CI 1.12-4.29 for each score increase in Frail Score).

Conclusion

This study revealed the reference data of frailty assessment in older patients with ACS in Vietnam. Our result indicated that over 30% of ACS older patients presented with frailty which was associated with an increased risk of in-hospital adverse outcomes and NACE. This study also provided promising information about the simple FRAIL scale's potential role in the risk stratification of older patients with ACS.

[Supporting the frail elderly: from resilience to reducing hospitalizations]

The frail elderly population will most certainly continue to grow in the coming years. Consequently, the number of hospitalizations and the iatrogenic dependence linked to them will increase. In this context, it seems interesting to question frailty. Indeed, accompanying, in ambulatory care, these patients towards a resilient behavior is one of the roles of advanced practice nurses, which it would be judicious to deepen in order to decrease the recourse to hospitalization.

Extended use of dual antiplatelet therapy among older adults with acute coronary syndromes and associated variables: a cohort study

BACKGROUND

Current guidelines recommend extending the use of dual antiplatelet therapy (DAPT) beyond 1 year in patients with an acute coronary syndrome (ACS) and a high risk of ischaemia and low risk of bleeding. No data exist about the implementation of this strategy in older adults from routine clinical practice.

METHODS

We conducted a Spanish multicentre, retrospective, observational registry-based study that included patients with ACS but no thrombotic or bleeding events during the first year of DAPT after discharge and no indication for oral anticoagulants. High bleeding risk was defined according to the Academic Research Consortium definition. We assessed the proportion of cases of extended DAPT among patients 65 ≥ years that went beyond 1 year after hospitalisation for ACS and the variables associated with the strategy.

RESULTS

We found that 48.1% (928/1,928) of patients were aged ≥ 65 years. DAPT was continued beyond 1 year in 32.1% (298/928) of patients ≥ 65; which was a similar proportion as with their younger counterparts. There was no significant correlation between a high bleeding risk and DAPT duration. Contrastingly, there was a strong correlation between the extent of coronary disease and DAPT duration (p < 0.001). Other variables associated with extended DAPT were a higher left ventricle ejection fraction, a history of heart failure and a prior stent thrombosis.

CONCLUSION

There was no correlation between age and extended use of DAPT beyond 1 year in older patients with ACS. DAPT was extended in about one-third of patients ≥ 65 years. The severity of the coronary disease, prior heart failure, left ventricle ejection fraction and prior stent thrombosis all correlated with extended DAPT.

Antiplatelet Strategies for Older Patients with Acute Coronary Syndromes: Finding Directions in a Low-Evidence Field

Patients ≥ 75 years of age account for about one third of hospitalizations for acute coronary syndromes (ACS). Since the latest European Society of Cardiology guidelines recommend that older ACS patients use the same diagnostic and interventional strategies used by the younger ones, most elderly patients are currently treated invasively. Therefore, an appropriate dual antiplatelet therapy (DAPT) is indicated as part of the secondary prevention strategy to be implemented in such patients. The choice of the composition and duration of DAPT should be tailored on an individual basis, after careful assessment of the thrombotic and bleeding risk of each patient. Advanced age is a main risk factor for bleeding. Recent data show that in patients of high bleeding risk short DAPT (1 to 3 months) is associated with decreased bleeding complications and similar thrombotic events, as compared to standard 12-month DAPT. Clopidogrel seems the preferable P2Y12 inhibitor, due to a better safety profile than ticagrelor. When the bleeding risk is associated with a high thrombotic risk (a circumstance present in about two thirds of older ACS patients) it is important to tailor the treatment by taking into account the fact that the thrombotic risk is high during the first months after the index event and then wanes gradually over time, whereas the bleeding risk remains constant. Under these circumstances, a de-escalation strategy seems reasonable, starting with DAPT that includes aspirin and low-dose prasugrel (a more potent and reliable P2Y12 inhibitor than clopidogrel) then switching after 2-3 months to DAPT with aspirin and clopidogrel for up to 12 months.

Non-invasive coronary imaging in elderly population

Age is a non-modifiable cardiovascular risk factor, which leads to development and progression of chronic conditions, such as coronary artery disease, by promoting atherosclerosis. Aging is responsible for morphological structure changes of the coronary arteries and specific atherosclerotic plaque features, which can be studied with non-invasive coronary imaging techniques, particularly coronary CT angiography. The aim of this review is to evaluate current knowledge on this technique applied to the elderly population, and to describe CAD manifestation and plaque features of coronary atherosclerosis in this particular set of patients. We also discuss the clinical implication of frailty assessment and customization of diagnostic strategies in order to shift the approach from disease-centered to patient-centered care.

Impact of frailty on outcomes in acute ST-elevated myocardial infarctions undergoing percutaneous coronary intervention

AIMS

We analyzed the impact of frailty on readmission rates for ST-elevated myocardial infarctions (STEMIs) and the utilization of percutaneous coronary intervention (PCI) in STEMI admissions.

METHODS AND RESULTS

The 2016-2019 Nationwide Readmission Database was analyzed for patients admitted with an acute STEMI. Patients were categorized by frailty risk and analyzed for 30-day readmission risk after acute STEMIs, PCI utilization and outcomes, and healthcare resource utilization. Qualifying index admissions were found in 584,918 visits. Low risk frailty was noted in 78.20%, intermediate risk in 20.67%, and high risk in 1.14% of admissions. Thirty-day readmissions occurred in 7.74% of index admissions, increasing with frailty (p < 0.001). Readmission risk increased with frailty, 1.37 times with intermediate and 1.21 times with high-risk frailty. PCI was performed in 86.40% of low-risk, 66.03% of intermediate-risk, and 58.90% of high-risk patients (p < 0.001). Intermediate patients were 55.02% less likely and high-risk patients were 61.26% less likely to undergo PCI (p < 0.001). Length of stay means for index admissions were 2.96, 7.83, and 16.32 days for low, intermediate, and high-risk groups. Intermediate and high-risk frailty had longer length of stay, higher total cost, and were more likely to be discharged to a skilled facility (p < 0.001).

CONCLUSION

Among adult, all-payer inpatient visits, frailty discerned by the hospital frailty risk score was associated with increased readmissions, increased healthcare resource utilization, and lower PCI administration.

The Association Between the Clinical Frailty Scale and Adverse Health Outcomes in Older Adults in Acute Clinical Settings - A Systematic Review of the Literature

Background

Frail older adults experience higher rates of adverse health outcomes. Therefore, assessing pre-hospital frailty early in the course of care is essential to identify the most vulnerable patients and determine their risk of deterioration. The Clinical Frailty Scale (CFS) is a frailty assessment tool that evaluates pre-hospital mobility, energy, physical activity, and function to generate a score that ranges from very fit to terminally ill.

Purpose

To synthesize the evidence of the association between the CFS degree and all-cause mortality, all-cause readmission, length of hospital stay, adverse discharge destination, and functional decline in patients >65 years in acute clinical settings.

Design

Systematic review with narrative synthesis.

Methods

Electronic databases (PubMed, EMBASE, CINAHL, Scopus) were searched for prospective or retrospective studies reporting a relationship between pre-hospital frailty according to the CFS and the outcomes of interest from database inception to April 2020.

Results

Our search yielded 756 articles, of which 29 studies were included in this review (15 were at moderate risk and 14 at low risk of bias). The included studies represented 26 cohorts from 25 countries (N = 44166) published between 2011 and 2020. All included studies showed that pre-hospital frailty according to the CFS is an independent predictor of all adverse health outcomes included in the review.

Conclusion

A primary purpose of the CFS is to grade clinically increased risk (i.e. risk stratification). Our results report the accumulated knowledge on the risk-predictive performance of the CFS and highlight the importance of routinely including frailty assessments, such as the CFS, to estimate biological age, improve risk assessments, and assist clinical decision-making in older adults in acute care. Further research into the potential of the CFS and whether implementing the CFS in routine practice will improve care and patients' quality of life is warranted.

Physical performance tests and in-hospital outcomes in elective open chest heart surgery

Background

Physical performance tests are essential for a comprehensive health assessment, and have been described as predictors of disability and muscle mass decline after open chest heart surgery (OHS). We evaluated the association between physical performance tests with clinical outcomes after OHS in younger and older patients. Moreover, the ability of physical performance tests and European System for Cardiac Operative Risk Evaluation (Euroscore II) to predict death was assessed.

Methods

Elective OHS patients were evaluated before surgery with handgrip strength (HGS), 30-s Chair-Stand Test (30sCST), and timed up and go test (TUGT). The outcomes were post-surgical complications, total length of stay (LOS), time to walk (TW), time in invasive mechanical ventilation (TIMV), and in-hospital mortality. Data were stratified between patients < 60 (younger) and ≥ 60 years old (older).

Results

A total of 166 patients were included in the study (older, n = 89). The only physical test associated with mortality in the adjusted models was HGS in older patients (p = 0.03). Among older patients, both Euroscore II (AUC = 0.77) and HGS (AUC = 0.80) demonstrated good ability to predict death. Combining HGS and Euroscore II did not increase accuracy for mortality prediction (AUC = 0.83).

Conclusion

HGS performance was comparable to a well-established surgical risk score in evaluating in-hospital mortality after OHS, only in older patients. Functional testing before OHS could be a tool to improve risk stratification in these patients. Future intervention studies aiming to improve functional capacity before elective OHS can further clarify the impact of physical fitness in surgical recovery.

Impact of Frailty and Age on Clinical Outcomes in Patients Who Underwent Endovascular Therapy

PURPOSE

Information on the relationship between frailty and the outcome of endovascular therapy (EVT) in elderly patients with lower extremity peripheral artery disease (PAD) is scarce. This study aimed to reveal the impact of frailty on the prognosis of super-elderly patients who underwent EVT.

MATERIALS AND METHODS

From August 2015 to August 2016, 335 consecutive patients who underwent EVT were enrolled in the I-PAD registry from 7 institutes in Nagano prefecture. Among them, we categorized 323 patients into 4 groups according to age and the presence or absence of frailty as follows: elderly with frailty (age ≥ 75, Clinical Frailty Scale [CFS] ≥ 5), elderly without frailty (age ≥ 75, CFS ≤ 4), young with frailty (age < 75, CFS ≥ 5), and young without frailty (age < 75, CFS ≤ 4); we analyzed them accordingly. The primary endpoints were major adverse cardiovascular and limb events (MACLE), defined as a composite of cardiovascular death, myocardial infarction, stroke, admission for heart failure, major amputation, and revascularization. The secondary endpoint was cardiovascular death.

RESULTS

The median follow-up period was 2.7 years. In the elderly with frailty, elderly without frailty, young with frailty, and young without frailty groups, the freedom rates from MACLE were 34.9%, 55.7%, 35.4%, and 63.0%, respectively (p<0.001) and from all-cause death were 43.5%, 73.4%, 50.7%, and 90.9%, respectively (p<0.001). The freedom rates from MACLE were significantly higher among elderly patients with frailty than among young patients without frailty (55.7% vs 35.4%, p=0.01). In multivariate analysis, frailty was independently associated with MACLE incidence.

CONCLUSION

Frailty as defined by CFS might be a predictor of MACLE incidence in patients with PAD who underwent EVT. By considering treatment indications for patients with PAD by focusing on frailty rather than age, we may examine whether EVT policies are appropriate and manage patient and caregiver expectations for potential improvement in functional outcomes. Further studies are expected to investigate whether changes in frailty after EVT change prognosis.

Effect of comprehensive geriatric assessment for frail elderly patients operated for colorectal cancer—the colorectal cancer frailty study: study protocol for a randomized, controlled, multicentre trial

Background

Colorectal cancer (CRC) is the third most common cancer worldwide, with a median age of 72–75 years at diagnosis. Curative treatment usually involves surgery; if left untreated, symptoms may require emergency surgery. Therefore, most patients will be accepted for surgery, despite of high age or comorbidity. It is known that elderly patients suffer higher risks after surgery than younger patients, in terms of complications and mortality. Assessing frailty and offering frail elderly patients individualized treatment according to the comprehensive geriatric assessment (CGA) and care concept has been shown to improve the outcome for frail elderly patients in other clinical contexts.

Methods

This randomized controlled multicentre trial aims to investigate if CGA and care prior to curatively intended surgery for CRC in frail elderly patients will improve postoperative outcome. All patients ≥ 70 years with surgically curable CRC will be screened for frailty using the Clinical Frailty Scale (CFS-9). Frail patients will be offered inclusion. Randomization is stratified for colon or rectal cancer. Patients in the intervention group are, in addition to standard protocol, treated according to CGA and care. This consists of individualized assessments and interventions, established by a multiprofessional team. Patients in the control group are treated according to best known practice as stipulated by Swedish colorectal cancer treatment guidelines, within an enhanced recovery after surgery (ERAS) setting. The primary outcome is 90-day mortality. Secondary outcomes are the length of hospital stay and total number of hospital days within 3 months, discharge destination, 30-day readmission, ADL, safe medication assessment, CFS-9 score, complications, Health-Related Quality of Life (HRQoL) at 2-month follow-up in comparison to baseline measurements, health economical calculations including cost-effectiveness analysis based on costs of hospital care and primary care, mortality and HRQoL at baseline, 2- and 12-month follow-up and all-cause 1-year mortality.

Discussion

The trial is the first of its size and extent to investigate intervention with CGA and care prior to surgery for CRC in frail elderly patients. If this addition proves to be favourable, it could have implications on future care of frail elderly patients with CRC.

Trial registration

ClinicalTrials.gov NCT04358328. Registered on 4 February 2020

Supplementary Information

The online version contains supplementary material available at 10.1186/s13063-022-06883-9.

A visualization analysis of hotspots and frontiers of cardiovascular diseases with frailty

Cardiovascular diseases (CVD) and frailty are common health problems among the elderly. This research aims to investigate the hotspots and frontiers of the field of CVD with frailty. Data of publications between 2000 and 2021 were collected from the Web of Science Core Collection (WoSCC) and CiteSpace was used for analyzing the hotspots and frontiers of cardiovascular diseases with frailty research from high-impact countries/regions, institutions, authors, cited references, cited journals, high-frequency keywords, and burst keywords. The results showed that the USA, England, and Canada were the leading countries/regions in research on CVD with frailty. Other countries/regions and regions lagged behind these developed countries/regions. There is a need to establish cooperation between developed countries/regions and developing countries/regions. Research hotspots focused on frailty in the elderly with CVD, exercise intervention, assessment for CVD patients with frailty, quality of life, and common diseases related to CVD with frailty. The frontier fields include care and intervention of CVD patients with frailty, social frailty, and validation of CVD with frailty.

The Clinical Frailty Scale (CFS) employment in the frailty assessment of patients suffering from Non-Communicable Diseases (NCDs): A systematic review

Background

The Clinical Frailty Scale (CFS) is a well-established tool that has been widely employed to assess patients' frailty status and to predict clinical outcomes in the acute phase of a disease, but more information is needed to define the implications that this tool have when dealing with Non-Communicable Diseases (NCDs).

Methods

An electronic literature search was performed on PubMed, Scopus, EMBASE, Web of Science, and EBSCO databases to identify studies employing the CFS to assess frailty in patients with NCDs.

Findings

After database searching, article suitability evaluation, and studies' quality assessment, 43 studies were included in the systematic review. Researches were conducted mostly in Japan (37.5%), and half of the studies were focused on cardiovascular diseases (46.42%), followed by cancer (25.00%), and diabetes (10.71%). Simplicity (39.29%), efficacy (37.5%), and rapidity (16.07%) were the CFS characteristics mostly appreciated by the authors of the studies. The CFS-related results indicated that its scores were associated with patients' clinical outcomes (33.92%), with the presence of the disease (12.5%) and, with clinical decision making (10.71%). Furthermore, CFS resulted as a predictor of life expectancy in 23 studies (41.07%), clinical outcomes in 12 studies (21.43%), and hospital admissions/readmissions in 6 studies (10.71%).

Discussion

CFS was found to be a well-established and useful tool to assess frailty in NCDs, too. It resulted to be related to the most important disease-related clinical characteristics and, thus, it should be always considered as an important step in the multidisciplinary evaluation of frail and chronic patients.

Systematic review registration

https://www.crd.york.ac.uk/PROSPERO/display_record.asp? PROSPERO 2021, ID: CRD42021224214.

The hemodynamic performance of balloon-expandable aortic bioprostheses in the elderly: a comparison between rapid deployment and transcatheter implantation

BACKGROUND

Surgical aortic valve replacement with a rapid deployment valve (RDV) is a relatively recent treatment option. Aim of this study was to compare the hemodynamic performance of balloon-expandable (BE)-RDVs and BE-transcatheter heart valves (THVs) in a high surgical risk and frail-elderly population.

METHODS

BE-THVs and BE-RDVs were respectively implanted in 138 and 47 patients, all older than 75 years and with a Canadian Study of Health and Aging category of 5 or above. Echocardiographic assessment was performed at discharge and at six months.

RESULTS

At discharge, transprosthetic pressure gradients and indexed effective orifice area (iEOA) were similar in both cohorts. At six-month follow-up, BE-RDV showed lower peak (14.69 vs 20.86 mmHg; p <0.001) and mean (7.82 vs 11.83 mmHg; p <0.001) gradients, as well as larger iEOA (1.05 vs 0.84 cm²/m²; p <0.001). Similar findings were also shown considering only small sized valves. Moderate-to-severe paravalvular leakage was more prevalent in BE-THVs at discharge (14.49 vs 0.00%; p=0.032) and, considering exclusively small prostheses, at six months too (57.69 vs 15.00%; p=0.014). Nevertheless, BE-THVs determined amelioration in left ventricular ejection fraction (53.79 vs 60.14%; p <0.001), pulmonary artery systolic pressure (35.81 vs 33.15 mmHg; p=0.042) and tricuspid regurgitation severity (40.58 vs 19.57%; p=0.031) from discharge to mid-term follow-up.

CONCLUSIONS

BE-RDVs showed better hemodynamic performance, especially when implanted in small annulus. Despite their worse baseline conditions, transcatheter patients still exhibited a greater improvement of their echocardiographic profile at mid-term follow-up.

Management and Outcomes of ST-Segment Elevation Myocardial Infarction in Hospitalized Frail Patients in the United States

Cardiovascular diseases and frailty are common conditions of aging populations and often coexist. In this study, we examined the in-hospital management, outcomes, and resource use of frail patients hospitalized for ST-segment elevation myocardial infarction (STEMI). This was a retrospective analysis of the 2005-2014 data from the Nationwide Inpatient Sample. Patients were classified into to versus 'nonfrail' using the Johns Hopkins Adjusted Clinical Groups frailty-defining diagnosis indicator. The primary outcome was STEMI management, whereas secondary outcomes were in-hospital mortality, length of stay, and cost. Outcomes were compared between frail and nonfrail patients using propensity score-matched analysis. There were 1,360,597 STEMI hospitalizations, of which 36,316 (2.7%) were frail. Propensity score-matched analysis showed that in in-hospital management options for STEMI, the odds of overall revascularization (odds ratio [OR], 0.60; 95% confidence interval [CI], 0.55 to 0.65), percutaneous coronary intervention (OR, 0.53; 95% CI, 0.49 to 0.57), and coronary angiography (OR, 0.59; 95% CI, 0.55 to 0.64) were significantly lower for frail patients. The odds of receiving coronary artery bypass grafting (OR, 1.66; 95% CI, 1.48 to 1.86) and overall hemodynamic support (OR, 1.26; 95% CI, 1.15 to 1.39) were significantly higher for frail patients. In-hospital mortality (18.7% vs 8.2%, p <0.001), length of stay (7.7 vs 3.7 days, p <0.001) and costs ($90,060 vs $63,507, p <0.001) were significantly higher in frail patients. Our findings suggest that collaborative efforts by cardiologists and cardiovascular surgeons for identifying frailty in patients with STEMI and incorporating frailty in risk estimation measures may improve management strategies, resource use and optimize patient outcomes.

Invasive Management in Older Adults (≥80 Years) With Non-ST Elevation Myocardial Infarction

OBJECTIVE

To evaluate the association of invasive management (coronary angiogram) with all-cause mortality among older adult (≥80 years of age) patients presenting with non-ST elevation myocardial infarction (NSTEMI) by frailty status.

PATIENTS AND METHODS

This study used a retrospective cohort of consecutive older adult patients who were hospitalized with NSTEMI as their primary clinical diagnosis between August 1, 2008, and December 31, 2019. Cox regression models were applied with stratification by frailty status (low, medium, and high). Extensive sensitivity analyses were conducted including propensity score matching and inverse probability treatment weighting models.

RESULTS

The study population included 2317 patients with median age of 86 years (IQR, 83-90 years) of whom 1243 (53.6%) were men. Patients who were managed invasively (n=581 [25%]) were less likely to be frail (7% vs 44%, P<.001). During the follow-up (median, 19 months, IQR, 4-41 months), 1599 (69%) patients died. In a multivariable Cox model, invasive approach was associated with adjusted hazard ratio (HR) of 0.61 (95% CI, 0.53 to 0.71) for the risk of death. The benefit of invasive approach was consistent among low, medium, and high frailty subgroups with adjusted HRs of 0.74 (95% CI, 0.58 to 0.93), 0.65 (95% CI, 0.50 to 0.85), and 0.52 (95% CI, 0.34 to 0.78), respectively (P for interaction = 0.48). Results were consistent with propensity score matching and inverse probability treatment weighting analyses (HR, 0.6; 95% CI, 0.50 to 0.71 and HR, 0.67; 95% CI, 0.55 to 0.82, respectively). Sensitivity analysis addressing potential immortal time bias and residual confounding yielded similar results.

CONCLUSION

Invasive approach is associated with improved survival among older adults with NSTEMI irrespective of frailty status.

The prevalence of frailty and pre-frailty among geriatric hospital inpatients and its association with economic prosperity and healthcare expenditure: A systematic review and meta-analysis of 467,779 geriatric hospital inpatients

BACKGROUND

Frailty is a common and clinically significant condition among geriatric populations. Although well-evidenced pooled estimates of the prevalence of frailty exist within various settings and populations, presently there are none assessing the overall prevalence of frailty among geriatric hospital inpatients. The purpose of this review was to systematically search and analyse the prevalence of frailty among geriatric hospital inpatients within the literature and examine its associations with national economic indicators.

METHODS

Systematic searches were conducted on Ovid, Web of Science, Scopus, CINAHL Plus, and the Cochrane Library, encompassing all literature published prior to 22 November 2018, supplemented with manual reference searches. Included studies utilised a validated operational definition of frailty, reported the prevalence of frailty, had a minimum age ≥ 65 years, attempted to assess the whole ward/clinical population, and occurred among hospital inpatients. Two reviewers independently extracted data and assessed study quality.

RESULTS

Ninety-six studies with a pooled sample of 467,779 geriatric hospital inpatients were included. The median critical appraisal score was 8/9 (range 7-9). The pooled prevalence of frailty, and pre-frailty, among geriatric hospital inpatients was 47.4% (95% CI 43.7-51.1%), and 25.8% (95% CI 22.0-29.6%), respectively. Significant differences were observed in the prevalence of frailty stratified by age, prevalent morbidity, ward type, clinical population, and operational definition. No significant differences were observed in stratified analyses by sex or continent, or significant associations between the prevalence of frailty and economic indicators.

CONCLUSIONS

Frailty is highly prevalent among geriatric hospital inpatients. High heterogeneity exists within this setting based on various clinical and demographic characteristics. Pooled estimates reported in this review place the prevalence of frailty among geriatric hospital inpatients between that reported for community-dwelling older adults and older adults in nursing homes, outlining an increase in the relative prevalence of frailty with progression through the healthcare system.

Comparison of the prognostic value of frailty assessment tools in patients aged ≥ 65 years hospitalized in a cardiac care unit with acute coronary syndrome

BACKGROUND

Frailty is associated with adverse events in elderly patients with acute coronary syndrome (ACS). Our aim was to compare the prognostic value of four frailty scales in patients aged ≥ 65 years hospitalized with ACS in a cardiac care unit (CCU).

METHODS

Patients aged ≥ 65 years with ACS were included. Frailty was assessed using the Fried frailty scale (reference standard), the Edmonton Frail Scale (EFS), the FRAIL scale, and the Clinical frailty scale (CFS). The primary end point was all-cause mortality and the secondary end point was unscheduled rehospitalization.

RESULTS

One hundred and seventy four patients aged ≥ 65 years with ACS were recruited. The median follow-up was 637.5 days. Frailty was identified in 41.4%, 40.2%, 39.1% and 36.3% patients by the Fried frailty scale, EFS, FRAIL scale and CFS, respectively. The agreement coefficients were 0.88, 0.86, and 0.79 for the FRAIL scale, EFS and CFS, respectively. In the Cox regression model, frailty was associated with all-cause mortality regardless of the scale used (univariate: hazard ratio [HR] 95% CI = 10.5, 2.4-46.8 Fried frailty scale; 12.0, 2.7-53.4 FRAIL scale; 7.1, 2.0-25.2 EFS; 8.3, 2.4-29.6 CFS. Multivariate: HR = 5.1, 1.1-23.8 Fried frailty scale; 5.7, 1.2-26.8 FRAIL scale; 3.7, 1.0-14.0 EFS; 4.2, 1.1-15.9 CFS). The FRAIL scale had the highest HR. In the univariate analysis, frailty was associated with unscheduled rehospitalization (HR = 3.2, 1.7-6.0 Fried frailty scale; 3.4, 1.8-6.3 FRAIL scale; 3.5, 1.8-6.6 EFS; 3.1, 1.7-5.8 CFS). In the multivariate analysis, only the EFS independently predicted unscheduled rehospitalization (HR = 2.2, 1.1-4.63).

CONCLUSIONS

Frailty assessed by the Fried frailty scale, FRAIL scale, EFS and CFS is associated with all-cause mortality and unscheduled rehospitalization in elderly patients hospitalized in a CCU with ACS. The adjusted HR of the FRAIL scale for all-cause mortality was the highest among the scales compared, whereas the EFS was an independent predictor of unscheduled rehospitalization. These data should be taken into consideration when choosing a frailty assessment tool.

Five-year clinical outcomes in patients with frailty aged ≥75 years with non-ST elevation acute coronary syndrome undergoing invasive management

Aim

Frailty is associated with adverse outcomes in older patients with acute coronary syndrome (ACS). The impact of frailty on long-term clinical outcomes following invasive management of non-ST elevation ACS (NSTEACS) is unknown.

Methods and results

The multi-centre Improve Clinical Outcomes in high-risk patieNts with ACS 1 (ICON-1) prospective cohort study consisted of patients aged >75 years undergoing coronary angiography following NSTEACS. Patients were categorized by frailty assessed by Canadian Study of Health and Ageing Clinical Frailty Scale (CFS) and Fried criteria. The primary composite endpoint was all-cause mortality, unplanned revascularization, myocardial infarction, stroke, and bleeding. Of 263 patients, 33 (12.5%) were frail, 152 (57.8%) were pre-frail, and 78 (29.7%) were robust according to CFS. By Fried criteria, 70 patients (26.6%, mean age 82.1 years) were frail, 147 (55.9%, mean age 81.3 years) were pre-frail, and 46 (17.5%, mean age 79.9 years) were robust. The composite endpoint was more common at 5 years among patients with frailty according to CFS (frail: 22, 66.7%; pre-frail: 81, 53.3%; robust: 27, 34.6%, P = 0.003), with a similar trend when using Fried criteria (frail: 39, 55.7%; pre-frail: 72, 49.0%; robust: 16, 34.8%, P = 0.085). Frailty measured with both CFS and Fried criteria was associated with the primary endpoint [age and sex-adjusted hazard ratio (HR) compared with robust groups. CFS: 2.22, 95% confidence interval (CI) 1.23–4.02, P = 0.008; Fried: HR 1.81, 95% CI 1.00–3.27, P = 0.048].

Conclusion

In older patients who underwent angiography following NSTEACS, frailty is associated with an increased risk of the primary composite endpoint at 5 years.

Registration:

Clinicaltrials.gov NCT01933581

Incidence and Predictors of Frailty Progression among Octogenarians with ST-elevation Myocardial Infarction Undergoing Primary Percutaneous Coronary Intervention

BACKGROUND

Frailty is one of the most serious health problems in older individuals with cardiovascular disease. Moreover, frailty progression is associated with subsequent adverse outcomes; therefore, the prevention of frailty progression is an important clinical issue. However, the incidence and predictors of frailty progression following acute myocardial infarction have not yet been fully elucidated.

METHODS

The present study is a sub-analysis of an observational multicenter registry retrospectively evaluating clinical outcomes of 288 octogenarians who underwent primary percutaneous coronary intervention (PCI) for ST-elevation myocardial infarction (STEMI) between January 2014 and December 2016 at five hospitals. We identified 244 patients who survived until discharge and evaluated frailty at baseline and discharge using the Clinical Frailty Scale (CFS). We defined frailty progression as an increase of at least one level in the CFS score at discharge from baseline and assessed the predictors of frailty progression.

RESULTS

Frailty progression was observed in 29.5% of patients. Patients with frailty progression were older, had more severe conditions with a higher prevalence of Killip 4 status and mechanical circulatory support use, more frequently experienced in-hospital events such as stroke (4/72, 6% vs. 0/172, 0%, p = 0.007), and had longer hospital stays than those without frailty progression [19 (11-35) vs. 13 (9-19) days, p<0.01]. Multivariate analysis showed that age (odds ratio 1.08, 95% confidence interval 1.00-1.17, p = 0.046) and Killip 4 status at baseline (odds ratio 3.34, 95% confidence interval 1.26-8.85, p = 0.01) were significant predictors of frailty progression.

CONCLUSIONS

In-hospital frailty progression was commonly observed in octogenarians with STEMI who underwent primary PCI and survived until discharge, and was associated with more severe clinical conditions.

Global cognitive function correlates with P-wave dispersion in frail hypertensive older adults

P‐Wave Dispersion (PWD) is an ECG parameter defined as the difference between the longest and the shortest P‐Wave duration. PWD has been associated with hypertension, a leading cause of age‐related cognitive decline. Moreover, hypertension is associated with vascular dementia and Alzheimer's Disease. Based on these considerations, we evaluated PWD and global cognitive function in frail hypertensive older adults with a previous diagnosis of cognitive decline. We evaluated consecutive frail hypertensive patients ≥65‐year‐old with a Mini‐Mental State Examination (MMSE) score <26. Patients with evidence of secondary hypertension, history of stroke, myocardial infarction, or therapy with beta‐blockers or acetylcholinesterase inhibitors were excluded. Beta‐blocker therapy causes a significant decrease in PWD; patients treated with acetylcholinesterase inhibitors were not included to avoid confounding effects on cognitive function. By examining 180 patients, we found that PWD significantly correlated with MMSE score. Strikingly, these effects were confirmed in a linear multivariate analysis with a regression model. To our knowledge, this is the first study showing that PWD correlates with global cognitive function in frail hypertensive older adults.

Clinical Frailty Scale classes are independently associated with 6-month mortality for patients after acute myocardial infarction

Aims

Data on the prognostic value of frailty to guide clinical decision-making for patients with myocardial infarction (MI) are scarce. To analyse the association between frailty classification, treatment patterns, in-hospital outcomes, and 6-month mortality in a large population of patients with MI.

Methods and results

An observational, multicentre study with a retrospective analysis of prospectively collected data using the SWEDEHEART registry. In total, 3381 MI patients with a level of frailty assessed using the Clinical Frailty Scale (CFS-9) were included. Of these patients, 2509 (74.2%) were classified as non-vulnerable non-frail (CFS 1–3), 446 (13.2%) were vulnerable non-frail (CFS 4), and 426 (12.6%) were frail (CFS 5–9). Frailty and non-frail vulnerability were associated with worse in-hospital outcomes compared with non-frailty, i.e. higher rates of mortality (13.4% vs. 4.0% vs. 1.8%), cardiogenic shock (4.7% vs. 2.5% vs. 1.9%), and major bleeding (4.5% vs. 2.7% vs. 1.1%) (all P < 0.001), and less frequent use of evidence-based therapies. In Cox regression analyses, frailty was strongly and independently associated with 6-month mortality compared with non-frailty, after adjustment for age, sex, the GRACE risk score components, and other potential risk factors [hazard ratio (HR) 3.32, 95% confidence interval (CI) 2.30–4.79]. A similar pattern was seen for vulnerable non-frail patients (fully adjusted HR 2.07, 95% CI 1.41–3.02).

Conclusion

Frailty assessed with the CFS was independently and strongly associated with all-cause 6-month mortality, also after comprehensive adjustment for baseline differences in other risk factors. Similarly, non-frail vulnerability was independently associated with higher mortality compared with those with preserved functional ability.

Functional tests in patients with ischemic heart disease

Lately, easier and shorter tests have been used in the functional evaluation of cardiac patients. Among these, walking speed (WS) and Timed Up and Go (TUG) tests are associated with all-cause mortality, mainly cardiovascular and the rate of re-hospitalization, especially in the elderly population. We prospectively analyzed a group of 38 patients admitted to the Cardiology Clinic from Elias Hospital, Romania, with chronic coronary syndrome (CCS) (n=22) and STEMI (n=16). We assessed the patients immediately after admission and before discharge with G-WALK between the 1^st and 30^th of September 2019. Our study group had a mean age of 62.7±12.1 years. Patients with a low WS were older (69.90±12.84 vs. 59.90±10.32 years, p=0.02) and had a lower serum hemoglobin (12.38±1.20 vs. 13.72±2.07 g/dl, p=0.02). The WS significantly improved during hospitalization (p=0.03) after optimal treatment. The TUG test performed at the time of admission had a longer duration in patients with heart failure (14.05 vs. 10.80 sec, p=0.02) and was influenced by patients' age (r=0.567, p=0.02), serum creatinine (r=0.409, p=0.03) and dilation of right heart chambers (r=0.399, p=0.03). WS and TUG tests can be used in patients with CCS and STEMI, and are mainly influenced by age, thus having a greater value among the elderly.

Is the contemporary care of the older persons with acute coronary syndrome evidence-based?

Globally, ischaemic heart disease is the leading cause of death, with a higher mortality burden amongst older adults. Although advancing age is associated with a higher risk of adverse outcomes following acute coronary syndrome (ACS), older patients are less likely to receive evidence-based medications and coronary angiography. Guideline recommendations for managing ACS are often based on studies that exclude older patients, and more contemporary trials have been underpowered and produced inconsistent findings. There is also limited evidence for how frailty and comorbidity should influence management decisions. This review focuses on the current evidence base for the medical and percutaneous management of ACS in older patients and highlights the distinct need to enrol older patients with ACS into well-powered, large-scale randomized trials.

Early angiography in elderly patients with non-ST-segment elevation acute coronary syndrome: The cardio CHUS-HUSJ registry

BACKGROUND

In elderly patients with non-ST elevation acute coronary syndrome (NSTEACS), while routine invasive management is established in high-risk NSTEACS patients, there is still uncertainty regarding the optimal timing of the procedure.

METHODS

This study analyzes the association of early coronary angiography with all-cause mortality, cardiovascular mortality, heart failure (HF) hospitalization, and major adverse cardiovascular events (MACE) in patients older than 75 years old with NSTEACS. This retrospective observational study included 7811 consecutive NSTEACS patients who were examined between the years 2003 and 2017 at two Spanish university hospitals. There were 2290 patients older than 75 years old. We compared their baseline characteristics according to the early invasive strategy used (coronarography ≤24 h vs. coronarography >24 h) after the diagnosis of NSTEACS.

RESULTS

Among the study participants, 1566 patients (68.38%) underwent early invasive coronary intervention. The mean follow-up period was 46 months (interquartile range 18-71 months). This association was also maintained after propensity score matching: early invasive strategy was significantly related to lower all-cause mortality [HR 0.61 (95% CI 0.51-0.71)], cardiovascular mortality [HR 0.52 (95% CI 0.43-0.63)], and MACE [HR 0.62 (CI 95% 0.54-0.71)].

CONCUSIONS

In a contemporary real-world registry of elderly NSTEACS patients, early invasive management significantly reduced all-cause mortality, cardiovascular mortality, and MACE during long-term follow-up.

BRIEF SUMMARY

In this real-world retrospective observational study that included 2451 patients older than 75 years old, 1566 patients (68.38%) underwent early invasive coronary intervention. After performing a propensity score matching, the early invasive strategy was still associated with lower all-cause mortality [HR (hazard ratio) 0.61, 95% CI (95% confidence interval) (0.51-0.71)], cardiovascular mortality [HR 0.52 (95%CI 0.43-0.63)], and MACE [HR 0.62 (95%CI 0.54-0.71)] during long-term follow-up.

Identifying impacts of air pollution on subacute asthma symptoms using digital medication sensors

BACKGROUND

Objective tracking of asthma medication use and exposure in real-time and space has not been feasible previously. Exposure assessments have typically been tied to residential locations, which ignore exposure within patterns of daily activities.

METHODS

We investigated the associations of exposure to multiple air pollutants, derived from nearest air quality monitors, with space-time asthma rescue inhaler use captured by digital sensors, in Jefferson County, Kentucky. A generalized linear mixed model, capable of accounting for repeated measures, over-dispersion and excessive zeros, was used in our analysis. A secondary analysis was done through the random forest machine learning technique.

RESULTS

The 1039 participants enrolled were 63.4% female, 77.3% adult (>18) and 46.8% White. Digital sensors monitored the time and location of over 286 980 asthma rescue medication uses and associated air pollution exposures over 193 697 patient-days, creating a rich spatiotemporal dataset of over 10 905 240 data elements. In the generalized linear mixed model, an interquartile range (IQR) increase in pollutant exposure was associated with a mean rescue medication use increase per person per day of 0.201 [95% confidence interval (CI): 0.189-0.214], 0.153 (95% CI: 0.136-0.171), 0.131 (95% CI: 0.115-0.147) and 0.113 (95% CI: 0.097-0.129), for sulphur dioxide (SO2), nitrogen dioxide (NO2), fine particulate matter (PM2.5) and ozone (O3), respectively. Similar effect sizes were identified with the random forest model. Time-lagged exposure effects of 0-3 days were observed.

CONCLUSIONS

Daily exposure to multiple pollutants was associated with increases in daily asthma rescue medication use for same day and lagged exposures up to 3 days. Associations were consistent when evaluated with the random forest modelling approach.

Prevalence and determinants of frailty in older adult patients with chronic coronary syndrome: a cross-sectional study

BACKGROUND

Frailty is an expression of vulnerability and decline of physical, mental, and social activities, more commonly found in older adults. It is also closely related to the occurrence and poor prognosis of coronary artery disease (CAD). Little investigation has been conducted on the prevalence and determinants of frailty in older adult patients with chronic coronary syndrome (CCS).

METHODS

A cross-sectional study was conducted, simple random sampling was used in this study. 218 older adults (age ≥ 60 years) with CCS with an inpatient admission number ending in 6 were randomly selected who hospitalized in Department of Geriatric Cardiology, Shandong Provincial Hospital Affiliated to Shandong First Medical University, China, between January and December 2018. For measurement and assessment, we used the 5-item FRAIL scale (fatigue, resistance, ambulation, illnesses, and loss of weight), demographic characteristics, Barthel Index(BI), Mini-Mental State Examination (MMSE), Geriatric Depression Scale (GDS-15), Mini Nutrition Assessment Shor-Form (MNA-SF), Morse Fall Scale (MFS), Caprini risk assessment, polypharmacy, and Numerical Rating Scale (NRS). Multivariate logistic regression analysis was used to confirme determinants.

RESULTS

The FRAIL scale showed 30.3% of the subjects suffered from frailty. Determinants were aging (OR1.12; 95% CI 1.04 ~ 1.62), out-of-pocket (OR18.93; 95% CI 1.11 ~ 324.07), hearing dysfunction (OR9.43; 95% CI 1.61 ~ 55.21), MNA-SF score (OR0.71; CI 0.57 ~ 0.89), GDS-15 score (OR1.35; 95% CI 1.11 ~ 1.64), and Caprini score (OR1.34; 95% CI 1.06 ~ 1.70).

CONCLUSIONS

The FRAIL scale confirmed that the prevalence of frailty in patients with CCS was slightly lower than CAD. Aging, malnutrition, hearing dysfunction, depression, and VTE risk were significantly associated with frail for older adult patients with CCS. A comprehensive assessment of high-risk patients can help identify determinants for frailty progression. In the context of CCS, efforts to identify frailty are needed, as are interventions to limit or reverse frailty status in older CCS patients.

Frailty Scales for Prognosis Assessment of Older Adult Patients after Acute Myocardial Infarction

We aimed to compare the prognostic value of two different measures, the Fried's Frailty Scale (FFS) and the Clinical Frailty Scale (CFS), following myocardial infarction (MI). We included 150 patients ≥ 70 years admitted from AMI. Frailty was evaluated on the day before discharge. The primary endpoint was number of days alive and out of hospital (DAOH) during the first 800 days. Secondary endpoints were mortality and a composite of mortality and reinfarction. Frailty was diagnosed in 58% and 34% of patients using the FFS and CFS scales, respectively. During the first 800 days 34 deaths and 137 admissions occurred. The number of DAOH decreased significantly with increasing scores of both FFS (p < 0.001) and CFS (p = 0.049). In multivariate analysis, only the highest scores (FFS = 5, CFS ≥ 6) were independently associated with fewer DAOH. At a median follow-up of 946 days, frailty assessed both by FFS and CFS was independently associated with death and MI (HR = 2.70 95%CI = 1.32-5.51 p = 0.001; HR = 2.01 95%CI = 1.1-3.66 p = 0.023, respectively), whereas all-cause mortality was only associated with FFS (HR = 1.51 95%CI = 1.08-2.10 p = 0.015). Frailty by FFS or CFS is independently associated with shorter number DAOH post-MI. Likewise, frailty assessed by either scale is associated with a higher rate of death and reinfarction, whereas FFS outperforms CFS for mortality prediction.

Acute Coronary Syndrome in the Older Patient

Coronary artery disease is one of the leading causes of morbidity and mortality, and its prevalence increases with age. The growing number of older patients and their differential characteristics make its management a challenge in clinical practice. The aim of this review is to summarize the state-of-the-art in diagnosis and treatment of acute coronary syndromes in this subgroup of patients. This comprises peculiarities of ST-segment elevation myocardial infarction (STEMI) management, updated evidence of non-STEMI therapeutic strategies, individualization of antiplatelet treatment (weighting ischemic and hemorrhagic risks), as well as assessment of geriatric conditions and ethical issues in decision making.

Management of acute coronary syndromes in older adults

Older patients are underrepresented in prospective studies and randomized clinical trials of acute coronary syndromes (ACS). Over the last decade, a few specific trials have been conducted in this population, allowing more evidence-based management. Older adults are a heterogeneous, complex, and high-risk group whose management requires a multidimensional clinical approach beyond coronary anatomic variables. This review focuses on available data informing evidence-based interventional and pharmacological approaches for older adults with ACS, including guideline-directed management. Overall, an invasive approach appears to demonstrate a better benefit-risk ratio compared to a conservative one across the ACS spectrum, even considering patients' clinical complexity and multiple comorbidities. Conversely, more powerful strategies of antithrombotic therapy for secondary prevention have been associated with increased bleeding events and no benefit in terms of mortality reduction. An interdisciplinary evaluation with geriatric assessment should always be considered to achieve a holistic approach and optimize any treatment on the basis of the underlying biological vulnerability.

Chest pain and acute coronary syndrome in octogenarians admitted to the Emergency Department

BACKGROUND

Although chest pain and acute coronary syndrome (ACS) are among the most common complaints in the Emergency Departments (ED), little is known about this topic in the octogenarian population.

OBJECTIVES

This study aimed to describe the clinical presentation and to evaluate survival time according to the ACS type in a group of 80-year-old or over patients admitted for chest pain to an ED.

METHODS

Patients were classified according to the discharge diagnosis. A multivariable Cox regression analysis was done to assess the association between ACS type and mortality with the non-ACS chest pain group as the reference category.

RESULTS

ACS was diagnosed in 170 of the 391 patients analyzed and 51% of ACS patients were female. Within the ACS patients, 18.8% presented STEMI, 57% NSTEMI, and 24% unstable angina (UA). Most of the patients were treated conservatively. In the adjusted analysis, the incidence of death at 40 months of follow-up was higher in patients with STEMI (HR 3.24; CI 1.59-6.56) than NSTEMI (HR 2.53; CI 1.56-4.11). There was no difference between patients with UA and the non-ACS group (HR 0.64; CI 0.26-1.58), and myocardial revascularization was associated with reduced mortality risk (HR 0.45; CI 0.22-0.92).

CONCLUSIONS

A high prevalence of ACS was found among octogenarians admitted to the ED with chest pain, and the ACS type behaved as an independent predictor of mortality. Patients with UA diagnosis had a similar prognosis to patients with non-ACS chest pain, but this needs to be demonstrated by a prospective study.

Multidimensional Prognostic Index (MPI) in elderly patients with acute myocardial infarction

BACKGROUND

Management of elderly patients with acute myocardial infarction (AMI) is challenging due to lack of knowledge about the link between fragility, outcomes and interventional procedures.

AIMS

The aim of this study was to establish the prognostic role of the Multidimensional Prognostic Index (MPI) in elderly with AMI.

METHODS

A total of 241 patients ≥ 65 years old with AMI were continuously enrolled in this prospective study and divided into three groups according to the MPI score. The primary endpoint was 30-day mortality. Secondary endpoints were 6-month mortality and rate of adverse events.

RESULTS

In-hospital overall mortality rate was higher in MPI-3 (p = 0.009). Patients of MPI-3 had a significantly higher mortality rate regarding the primary endpoint with 30-day survival of 78.9%, compared to 97.4% and 97.2%, in MPI-1, MPI-2 (p < 0.001), respectively. The survival rate progressively decreased in the three MPI classes of risk with a 6-month survival of 96.5%, 96.3%, 73.7% in groups MPI-1, MPI-2, and MPI-3 (p < 0.001). Longer length of in-hospital stay was observed in MPI-3 group. In-hospital complications were more frequent in higher MPI score.

DISCUSSION

Our findings are in agreement with the results of other studies that evaluated the risk of in-hospital complications and mortality in older patients. In our "real-world" population of elderly hospitalized for AMI we observed poorer outcomes in patients belonged to higher MPI groups.

CONCLUSIONS

In the setting of AMI, MPI may be very useful in the daily clinical practice to manage older patients and predict the risk of in-hospital and follow-up complications.

Multidimensional Prognostic Index (MPI) in elderly patients with acute myocardial infarction

Background

Management of elderly patients with acute myocardial infarction (AMI) is challenging due to lack of knowledge about the link between fragility, outcomes and interventional procedures.

Aims

The aim of this study was to establish the prognostic role of the Multidimensional Prognostic Index (MPI) in elderly with AMI.

Methods

A total of 241 patients ≥ 65 years old with AMI were continuously enrolled in this prospective study and divided into three groups according to the MPI score. The primary endpoint was 30-day mortality. Secondary endpoints were 6-month mortality and rate of adverse events.

Results

In-hospital overall mortality rate was higher in MPI-3 (p = 0.009). Patients of MPI-3 had a significantly higher mortality rate regarding the primary endpoint with 30-day survival of 78.9%, compared to 97.4% and 97.2%, in MPI-1, MPI-2 (p < 0.001), respectively. The survival rate progressively decreased in the three MPI classes of risk with a 6-month survival of 96.5%, 96.3%, 73.7% in groups MPI-1, MPI-2, and MPI-3 (p < 0.001). Longer length of in-hospital stay was observed in MPI-3 group. In-hospital complications were more frequent in higher MPI score.

Discussion

Our findings are in agreement with the results of other studies that evaluated the risk of in-hospital complications and mortality in older patients. In our “real-world” population of elderly hospitalized for AMI we observed poorer outcomes in patients belonged to higher MPI groups.

Conclusions

In the setting of AMI, MPI may be very useful in the daily clinical practice to manage older patients and predict the risk of in-hospital and follow-up complications.

Validation of the revised 9-scale clinical frailty scale (CFS) in Greek language

BACKGROUND

Among many screening tools that have been developed to detect frailty in older adults, Clinical Frailty Scale (CFS) is a valid, reliable and easy-to-use tool that has been translated in several languages. The aim of this study was to develop a valid and reliable version of the CFS to the Greek language.

METHODS

A Greek version was obtained by translation (English to Greek) and back translation (Greek to English). The "known-group" construct validity of the CFS was determined by using test for trends. Criterion concurrent validity was assessed by evaluating the extent that CFS relates to Barthel Index, using Pearson's correlation coefficient. Both inter-rater and test-retest reliability were assessed using intraclass correlation coefficient.

RESULTS

Known groups comparison supports the construct validity of the CFS. The strong negative correlation between CFS and Barthel Index (rs = - 0,725, p ≤ 0.001), supports the criterion concurrent validity of the instrument. The intraclass correlation was good for both inter-rater (0.87, 95%CI: 0.82-0.90) and test-retest reliability (0.89: 95%CI: 0.85-0.92).

CONCLUSION

The Greek version of the CFS is a valid and reliable instrument for the identification of frailty in the Greek population.

Outcomes of Nonagenarians With Acute Coronary Syndrome

OBJECTIVES

Nonagenarians are a fast-growing age group among cardiovascular patients, but data about their management and prognosis after an acute coronary syndrome (ACS) is scarce. This study aimed to analyze characteristics of nonagenarian patients with ACS and to compare in-hospital and 1-year clinical outcomes between those treated with medical treatment (MT) alone and those receiving percutaneous coronary intervention (PCI).

DESIGN

Multicenter observational study.

SETTING AND PARTICIPANTS

We included consecutive nonagenarian patients with ACS admitted at 4 academic centers between 2005 and 2018. Only patients with type 1 myocardial infarction were included.

METHODS

Standardized definitions of all patient-related variables, clinical diagnoses, and hospital complications and outcomes were used. The primary endpoint was 1-year all-cause mortality. Long-term survival was compared between patients undergoing PCI and those managed with MT alone. Given differences in baseline characteristics could substantially interfere in outcomes, 3 sensitivity analyses were performed to adjust for confounders.

RESULTS

A total of 680 nonagenarians were included (59% females). Of them, 373 (55%) patients presented with non-ST-segment elevation ACS (NSTE-ACS) and 307 (45%) with ST-segment elevation myocardial infarction (STEMI). A coronary angiogram was performed in 115 (31%) of NSTE-ACS and in 182 (60%) of STEMI patients with subsequent PCI in 81 (22%) and 156 (51%), respectively. Overall mortality rates were 17% in-hospital and 39% at 1-year follow-up. PCI was independently associated with a decreased risk of 1-year all-cause death [hazard ratio (HR) 0.57, 95% confidence interval (CI) 0.35, 0.95; P < .05], mainly observed in those patients without disability (HR 0.59, 95% CI 0.37, 0.94; P < .01) and lower Killip class (HR 0.50, 95% CI 0.28, 0.89; P < .001).

CONCLUSIONS AND IMPLICATIONS

The prognosis of nonagenarians after an ACS was associated with comorbidities and the therapeutic approach. Although PCI appeared to be a safe and effective strategy, it is still necessary to refine the decision-making process in this high-risk population group.