Editor's Choice - Frailty and the management of patients with acute cardiovascular disease: A position paper from the Acute Cardiovascular Care Association

Effects of routine invasive management on reinfarction risk in older adults with frailty and non-ST-segment elevation myocardial infarction: a subanalysis of a randomised clinical trial

BACKGROUND

Clinical trials and meta-analyses indicate a reduced reinfarction risk with invasive management in older patients with non-ST-segment elevation myocardial infarction (NSTEMI). This study investigated whether similar benefits might be observed in frail patients.

METHODS

The coMOrbilidades Síndrome Coronario Agudo - FRAIL (MOSCA-FRAIL) trial included 167 adults aged ≥70 years with frailty (Clinical Frailty Scale ≥4 points) and NSTEMI, who were randomised to invasive (n=84) or conservative (n=83) strategy during the index hospitalisation. The primary end point of this subanalysis was reinfarction, considering all-cause mortality as a competing event, at a 3-year median follow-up. The time to first reinfarction and all reinfarctions (first and recurrent) were considered. The substudy was not prespecified.

RESULTS

The total number of deaths (93, 56%) exceeded that of first reinfarctions (32, 19%). Invasive treatment did not influence the reinfarction risk when accounting for death as a competing risk (subdistribution HR=0.87, 95% CI 0.54 to 1.40, p=0.56). An initially increased mortality risk with invasive management (significant between days 131 and 175) shifted to a lower mortality risk over time. A total of 45 reinfarctions (first and recurrent) were observed. The longitudinal trajectories corroborated that the invasive strategy did not reduce the risk of reinfarction over time (p=0.72). However, mortality followed a biphasic pattern, with higher mortality in the invasive group during the first 6 months and a reduction between 9 months and 3 years (p=0.05 for the entire time-dependent trajectory). The win ratio for the invasive strategy versus the conservative strategy was 1.08 (95% CI 0.72 to 1.63, p=0.70).

CONCLUSIONS

In older adults with frailty and NSTEMI, routine invasive management did not reduce the reinfarction risk at a 3-year follow-up. The high all-cause mortality associated with frailty may limit the impact of invasive management. Due to the limited sample size and risk for type II error, these findings should be considered hypothesis-generating.

TRIAL REGISTRATION NUMBER

NCT03208153.

Frailty as an independent predictor for midterm adverse outcomes in the elderly undergoing primary percutaneous coronary intervention: A longitudinal cohort study

BACKGROUND

Frailty is associated with poor health outcomes in elderly population. However, its effect on midterm outcomes in elderly patients undergoing primary percutaneous coronary intervention (PCI) for ST-elevation myocardial infarction (STEMI) remains unknown.

AIMS

This study aimed to evaluate the association between frailty, as classified by the Clinical Frailty Scale (CFS), and midterm adverse outcomes in elderly STEMI patients after primary PCI.

METHODS

In this prospective, observational, multicenter cohort study, frailty status of 426 STEMI patients aged ≥60 years undergoing primary PCI was determined using the nine-point CFS 2 weeks before the occurrence of STEMI. Patients scoring at least four points on the CFS were considered frail. The primary outcome was a composite of cardiovascular death or readmission. Secondary outcomes included cardiovascular death, cardiovascular readmission, heart failure-related death or readmission, and myocardial reinfarction. Follow-up data were collected through medical record reviews and/or telephone interviews.

RESULTS

Of 426 elderly patients, 116 were frail. The median follow-up period was 15 months (interquartile range 5-19 months). Primary outcome events occurred in 87 (75.0%) frail and 75 (24.2%) nonfrail patients. The adjusted hazard ratio was 3.278 after model selection using the Bayesian Model Averaging approach (95% confidence interval 2.372-4.531). Multivariate Cox proportional hazard survival analysis showed that frailty was significantly associated with a higher prevalence of all secondary outcome events after adjusting for TIMI, PAMI, and CADILLAC risk scores.

CONCLUSIONS

Frailty, as defined by the CFS, was independently associated with midterm adverse outcomes in elderly patients undergoing primary PCI for STEMI.

[The older patient in intensive care]

Demographic trends mean that the proportion of older and very old patients in hospitals at all levels of care is increasing. This means that significantly more patients from these age groups can be expected in the future. These developments pose new challenges for both medical care and the management of geriatric intensive care patients, taking into account their multimorbidity and functional limitations due to acute illness. Although mortality increases with age, the outcome is highly dependent on the patient's functionality and comorbidity. The elderly patient also shows structural and functional organ changes, knowledge of which is important for the treatment of geriatric patients in intensive care medicine. This increasing need for geriatric treatment will have a decisive influence on the development of intensive care medicine in the coming years.

Latest evidence on assessment and invasive management of non-ST-segment elevation acute coronary syndrome (NSTE-ACS) in the older population

INTRODUCTION

Invasive management of non-ST-segment elevation acute coronary syndrome (NSTE-ACS) should be considered regardless of age, but a key challenge is deciding which patients are most likely to benefit from an invasive approach in the older population. In addition to assessment of the clinical signs and symptoms, a holistic assessment of geriatric syndromes such as frailty, multimorbidity and cognitive impairment is of increasing importance. Recent trials have validated the roles of physiological assessment and intracoronary imaging to guide revascularisation.

AREAS COVERED

This review focuses on the comparison between invasive and conservative management in the older population with NSTE-ACS, the clinical characteristics of the older population with NSTE-ACS, and the role of physiological assessment and intracoronary imaging to guide revascularisation in this cohort.

EXPERT OPINION

Invasive management in the older population with NSTE-ACS may not improve mortality but reduces the risk of non-fatal myocardial infarction and repeat revascularisation. Decisions surrounding invasive versus conservative management should be individualized to each patient, depending on patient preference, clinical features, comorbidities and frailty. In patients where invasive management is indicated, a combination of physiological assessment and intracoronary imaging is likely to improve revascularisation outcomes, especially in the context of complex anatomical characteristics like multivessel disease.

Development and validation of machine learning-derived frailty index in predicting outcomes of patients undergoing percutaneous coronary intervention

Introduction

Frailty is associated with increased mortality in patients with percutaneous coronary intervention (PCI). Existing operationalized frailty measurement tools are limited and require resource intensive process. We developed and validated a tool to identify and stratify frailty using collected data for patients who underwent PCI and explored its predictive power to predict adverse clinical outcomes post PCI.

Methods

Between 2014 and 2015, 1,732 patients who underwent semi-urgent or elective PCI in a tertiary centre were included. Variables including demographics, co-morbidities, investigations and clinical outcomes to 33 ± 37 months were analysed. Logistic regression model and Extreme Gradient Boosting (XGBoost) machine learning model were constructed to identify predictors of adverse clinical outcomes post PCI. The final models' predicted probabilities were assessed with area under receiver operating characteristic curve (AUC).

Results

With model analysis, frailty index (FI), age and gender were the 3 most important features for adverse clinical outcomes prediction, with FI contributing the most. After adjustment, the odds of FI to predict cardiac death and in-hospital death post PCI remained significant [1.94 (95 %CI1.79-2.10); p < 0.001, 2.04(95 %CI 1.87-2.23); p < 0.001 respectively]. The XGBoost machine learning models improved predictive power for cardiac death [AUC 0.83(95 %CI 0.80-0.86)] and in hospital death [AUC 0.83(95 %CI 0.80-0.86)] post PCI compared to logistic regression models.

Conclusion

The resultant model developed using novel machine learning methodologies had good predictive power for significant clinical outcomes post PCI with potential to be automated within hospital information systems.

Age-specific associations of invasive treatment with long-term mortality of patients with acute myocardial infarction: Results of a real-world cohort analysis

Background

To investigate the age-specific association between invasive treatment, that is percutaneous coronary intervention (PCI) or coronary artery bypass graft (CABG) at acute myocardial infarction (AMI) and all-cause long-term mortality.

Methods

The analysis was based on 4964 hospitalized AMI patients (age 25-84 years) registered by the population-based Augsburg Myocardial Infarction Registry between 2010 and 2017. The median follow-up time was 4.7 years (IQR: 2.7; 6.8). All-cause mortality was obtained by regularly checking the vital status of all registered AMI patients in cooperation with the regional population registries. In multivariable adjusted Cox regression analyses the age-specific associations between invasive therapy (PCI or CABG versus no invasive therapy) and all-cause mortality were investigated.

Results

During follow-up 1224 patients (805 men and 419 women) died. In patients younger than 55 years 7.6 %, in the age group 55-64 years 7.1 %, in the age group 65-74 years 12.2 %, and in the age group 75-84 years 21.6 % did not undergo invasive therapy (PCI or CABG) during hospital stay. Invasive therapy using PCI or CABG significantly reduced mortality risk in all age-groups in comparison to AMI patients without invasive treatment. Even 75-84 years old benefited very impressively from invasive therapy regarding long-term all-cause mortality (PCI: HR 0.55; 95 % CI 0.44-0.70; CABG: HR 0.43; 95 % CI 0.30-0.62).

Conclusions

Invasive or surgical therapy procedures in the treatment of AMI patients are effective in all age groups. Therefore, also old AMI patients should receive guideline-compliant therapy to achieve a better outcome.

Delirium and frailty in older adults: Clinical overlap and biological underpinnings

Frailty and delirium are two common geriatric syndromes sharing several clinical characteristics, risk factors, and negative outcomes. Understanding their interdependency is crucial to identify shared mechanisms and implement initiatives to reduce the associated burden. This literature review summarizes scientific evidence on the complex interplay between frailty and delirium; clinical, epidemiological, and pathophysiological commonalities; and current knowledge gaps. We conducted a PubMed systematic search in June 2023, which yielded 118 eligible articles out of 991. The synthesis of the results-carried out by content experts-highlights overlapping risk factors, clinical phenotypes, and outcomes and explores the influence of one syndrome on the onset of the other. Common pathophysiological mechanisms identified include inflammation, neurodegeneration, metabolic insufficiency, and vascular burden. The review suggests that frailty is a risk factor for delirium, with some support for delirium associated with accelerated frailty. The proposed unifying framework supports the integration and measurement of both constructs in research and clinical practice, identifying the geroscience approach as a potential avenue to develop strategies for both conditions. In conclusion, we suggest that frailty and delirium might be alternative-sometimes coexisting-manifestations of accelerated biological aging. Clinically, the concepts addressed in this review can help approach older adults with either frailty or delirium from a different perspective. From a research standpoint, longitudinal studies are needed to explore the hypothesis that specific pathways within the biology of aging may underlie the clinical manifestations of frailty and delirium. Such research will pave the way for future understanding of other geriatric syndromes as well.

Acute Coronary Syndrome in Elderly Patients: How to Tackle Them?

Elderly patients diagnosed with acute coronary syndromes (ACS) represent a growing demographic population. These patients typically present more comorbidities and experience poorer outcomes compared to younger patients. Furthermore, they are less frequently subjected to revascularization procedures and are less likely to receive evidence-based medications in both the short and long-term periods. Assessing frailty is crucial in elderly patients with ACS because it can influence management decisions, as well as risk stratification and prognosis. Indeed, treatment decisions should consider geriatric syndromes, frailty, polypharmacy, sarcopenia, nutritional deficits, prevalence of comorbidities, thrombotic risk, and, at the same time, an increased risk of bleeding. Rigorous clinical assessments, clear revascularization criteria, and tailored approaches to antithrombotic therapy are essential for guiding personalized treatment decisions in these individuals. Assessing frailty helps healthcare providers identify patients who may benefit from targeted interventions to improve their outcomes and quality of life. Elderly individuals who experience ACS remain significantly underrepresented and understudied in randomized controlled trials. For this reason, the occurrence of ACS in the elderly continues to be a particularly complex issue in clinical practice, and one that clinicians increasingly have to address, given the general ageing of populations. This review aims to address the complex aspects of elderly patients with ACS to help clinicians make therapeutic decisions when faced with such situations.

The electronic frailty index and outcomes in patients with myocardial infarction

BACKGROUND

Frailty is increasingly present in patients with acute myocardial infarction. The electronic Frailty Index (eFI) is a validated method of identifying vulnerable older patients in the community from routine primary care data. Our aim was to assess the relationship between the eFI and outcomes in older patients hospitalised with acute myocardial infarction.

STUDY DESIGN AND SETTING

Retrospective cohort study using the DataLoch Heart Disease Registry comprising consecutive patients aged 65 years or over hospitalised with a myocardial infarction between October 2013 and March 2021.

METHODS

Patients were classified as fit, mild, moderate, or severely frail based on their eFI score. Cox-regression analysis was used to determine the association between frailty category and all-cause mortality.

RESULTS

In 4670 patients (median age 77 years [71-84], 43% female), 1865 (40%) were classified as fit, with 1699 (36%), 798 (17%) and 308 (7%) classified as mild, moderate and severely frail, respectively. In total, 1142 patients died within 12 months of which 248 (13%) and 147 (48%) were classified as fit and severely frail, respectively. After adjustment, any degree of frailty was associated with an increased risk of all-cause death with the risk greatest in the severely frail (reference = fit, adjusted hazard ratio 2.87 [95% confidence intervals 2.24 to 3.66]).

CONCLUSION

The eFI identified patients at high risk of death following myocardial infarction. Automatic calculation within administrative data is feasible and could provide a low-cost method of identifying vulnerable older patients on hospital presentation.

Remotely monitored physical activity from older people with cardiac devices associates with physical functioning

INTRODUCTION

Accelerometer-derived physical activity (PA) from cardiac devices are available via remote monitoring platforms yet rarely reviewed in clinical practice. We aimed to investigate the association between PA and clinical measures of frailty and physical functioning.

METHODS

The PATTErn study (A study of Physical Activity paTTerns and major health Events in older people with implantable cardiac devices) enrolled participants aged 60 + undergoing remote cardiac monitoring. Frailty was measured using the Fried criteria and gait speed (m/s), and physical functioning by NYHA class and SF-36 physical functioning score. Activity was reported as mean time active/day across 30-days prior to enrolment (30-day PA). Multivariable regression methods were utilised to estimate associations between PA and frailty/functioning (OR = odds ratio, β = beta coefficient, CI = confidence intervals).

RESULTS

Data were available for 140 participants (median age 73, 70.7% male). Median 30-day PA across the analysis cohort was 134.9 min/day (IQR 60.8-195.9). PA was not significantly associated with Fried frailty status on multivariate analysis, however was associated with gait speed (β = 0.04, 95% CI 0.01-0.07, p = 0.01) and measures of physical functioning (NYHA class: OR 0.73, 95% CI 0.57-0.92, p = 0.01, SF-36 physical functioning: β = 4.60, 95% CI 1.38-7.83, p = 0.005).

CONCLUSIONS

PA from cardiac devices was associated with physical functioning and gait speed. This highlights the importance of reviewing remote monitoring PA data to identify patients who could benefit from existing interventions. Further research should investigate how to embed this into clinical pathways.

Linking Myocardial Infarction and Frailty Status at Old Age in Europe: Moderation Effects of Country and Gender

BACKGROUND

Myocardial infarction (MI) is a serious condition affecting a considerable number of individuals, with important clinical consequences. Understanding the associated factors is crucial for effective management and prevention. This study aimed to (1) examine the association between MI and frailty in a sample of older European adults and (2) investigate the moderating effects of country and gender on this association.

METHODS

A cross-sectional survey of 22,356 Europeans aged 60 years and older was conducted. The data come from the sixth wave of the Survey of Health, Ageing and Retirement in Europe. Frailty, MI, gender, and country were studied.

RESULTS

Frailty is strongly associated with MI. Robust older adults are 13.31 times more likely not to have an MI. However, these odds drop to 5.09 if pre-frail and to 2.73 if frail. Gender, but not country, moderates this relationship. There is a strong association between MI and frailty in men, whereas for women, the association is not as strong.

CONCLUSIONS

Frailty is highly associated with MI in European older adults. Country did not moderate the link between frailty and MI but gender does, with the relationship being notably stronger in men. The frailty-MI association remained significant even when controlling for a number of personal conditions and comorbidities.

Frailty and In-Hospital Outcomes for Management of Cardiogenic Shock without Acute Myocardial Infarction

(1) Background: Cardiogenic shock (CS) is associated with high morbidity and mortality. Frailty and cardiovascular diseases are intertwined, commonly sharing risk factors and exhibiting bidirectional relationships. The relationship of frailty and non-acute myocardial infarction with cardiogenic shock (non-AMI-CS) is poorly described. (2) Methods: We retrospectively analyzed the National Inpatient Sample from 2016 to 2020 and identified all hospitalizations for non-AMI-CS. We classified them into frail and non-frail groups according to the hospital frailty risk score cut-off of 5 and compared in-hospital outcomes. (3) Results: A total of 503,780 hospitalizations for non-AMI-CS were identified. Most hospitalizations involved frail adults (80.0%). Those with frailty had higher odds of in-hospital mortality (adjusted odds ratio [aOR] 2.11, 95% confidence interval [CI] 2.03-2.20, p < 0.001), do-not-resuscitate status, and discharge to a skilled nursing facility compared with those without frailty. They also had higher odds of in-hospital adverse events, such as acute kidney injury, delirium, and longer length of stay. Importantly, non-AMI-CS hospitalizations in the frail group had lower use of mechanical circulatory support but not rates of cardiac transplantation. (4) Conclusions: Frailty is highly prevalent among non-AMI-CS hospitalizations. Those accompanied by frailty are often associated with increased rates of morbidity and mortality compared to those without frailty.

Edoxaban for stroke prevention in atrial fibrillation and factors associated with dosing: patient characteristics from the prospective observational ETNA-AF-China registry

Real-world data on effectiveness and safety of a single non-vitamin K antagonist oral anticoagulant in the Chinese population with atrial fibrillation (AF) are limited. This study reports characteristics of patients treated with edoxaban and factors associated with dosing patterns from routine care in China. ETNA-AF-China (NCT04747496) is a multicentre, prospective, observational study enrolling edoxaban-treated patients from four economic regions with a targeted 2-year follow-up. Of the 4930 patients with AF (mean age: 70.2 ± 9.5 years; male, 57.1%), the mean creatinine clearance (CrCl), CHA2DS2-VASc, and HAS-BLED scores were 71.2 mL/min, 2.9, and 1.6. Overall, 6.4% of patients were perceived as frail by investigators. Available label dose reduction criteria (N = 4232) revealed that 3278 (77.5%) patients received recommended doses and 954 (22.5%) non-recommended doses. Northeast (53.0%) and West (43.1%) regions had the highest prescriptions of 60 mg and 30 mg recommended doses, respectively. Non-recommended 30 mg doses were more frequently prescribed in patients with antiplatelet use and history of heart failure than recommended 60 mg. Multivariate analysis identified advanced age as the strongest associated factor with non-recommended doses. Frailty had the strongest association with 30 mg except for age, and history of TIA was the most relevant factor associated with 60 mg. In conclusion, patients in the ETNA-AF-China study were predominantly aged 65 years and older, had mild-to-moderate renal impairment and good label adherence. Advanced age was associated with non-recommended doses, with frailty most common for non-recommended 30 mg and a history of TIA for the non-recommended 60 mg dose.

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 Routine Invasive vs Conservative Strategy in Older Adults With Frailty and Non-ST-Segment Elevation Acute Myocardial Infarction: A Randomized Clinical Trial

Importance

To our knowledge, no randomized clinical trial has compared the invasive and conservative strategies in frail, older patients with non-ST-segment elevation acute myocardial infarction (NSTEMI).

Objective

To compare outcomes of invasive and conservative strategies in frail, older patients with NSTEMI at 1 year.

Design, Setting, and Participants

This multicenter randomized clinical trial was conducted at 13 Spanish hospitals between July 7, 2017, and January 9, 2021, and included 167 older adult (≥70 years) patients with frailty (Clinical Frailty Scale score ≥4) and NSTEMI. Data analysis was performed from April 2022 to June 2022.

Interventions

Patients were randomized to routine invasive (coronary angiography and revascularization if feasible; n = 84) or conservative (medical treatment with coronary angiography for recurrent ischemia; n = 83) strategy.

Main Outcomes and Measures

The primary end point was the number of days alive and out of the hospital (DAOH) from discharge to 1 year. The coprimary end point was the composite of cardiac death, reinfarction, or postdischarge revascularization.

Results

The study was prematurely stopped due to the COVID-19 pandemic when 95% of the calculated sample size had been enrolled. Among the 167 patients included, the mean (SD) age was 86 (5) years, and mean (SD) Clinical Frailty Scale score was 5 (1). While not statistically different, DAOH were about 1 month (28 days; 95% CI, -7 to 62) greater for patients managed conservatively (312 days; 95% CI, 289 to 335) vs patients managed invasively (284 days; 95% CI, 255 to 311; P = .12). A sensitivity analysis stratified by sex did not show differences. In addition, we found no differences in all-cause mortality (hazard ratio, 1.45; 95% CI, 0.74-2.85; P = .28). There was a 28-day shorter survival in the invasive vs conservatively managed group (95% CI, -63 to 7 days; restricted mean survival time analysis). Noncardiac reasons accounted for 56% of the readmissions. There were no differences in the number of readmissions or days spent in the hospital after discharge between groups. Neither were there differences in the coprimary end point of ischemic cardiac events (subdistribution hazard ratio, 0.92; 95% CI, 0.54-1.57; P = .78).

Conclusions and Relevance

In this randomized clinical trial of NSTEMI in frail older patients, there was no benefit to a routine invasive strategy in DAOH during the first year. Based on these findings, a policy of medical management and watchful observation is recommended for older patients with frailty and NSTEMI.

Trial Registration

ClinicalTrials.gov Identifier: NCT03208153.

EHRA expert consensus document on the management of arrhythmias in frailty syndrome, endorsed by the Heart Rhythm Society (HRS), Asia Pacific Heart Rhythm Society (APHRS), Latin America Heart Rhythm Society (LAHRS), and Cardiac Arrhythmia Society of Southern Africa (CASSA)

There is an increasing proportion of the general population surviving to old age with significant chronic disease, multi-morbidity, and disability. The prevalence of pre-frail state and frailty syndrome increases exponentially with advancing age and is associated with greater morbidity, disability, hospitalization, institutionalization, mortality, and health care resource use. Frailty represents a global problem, making early identification, evaluation, and treatment to prevent the cascade of events leading from functional decline to disability and death, one of the challenges of geriatric and general medicine. Cardiac arrhythmias are common in advancing age, chronic illness, and frailty and include a broad spectrum of rhythm and conduction abnormalities. However, no systematic studies or recommendations on the management of arrhythmias are available specifically for the elderly and frail population, and the uptake of many effective antiarrhythmic therapies in these patients remains the slowest. This European Heart Rhythm Association (EHRA) consensus document focuses on the biology of frailty, common comorbidities, and methods of assessing frailty, in respect to a specific issue of arrhythmias and conduction disease, provide evidence base advice on the management of arrhythmias in patients with frailty syndrome, and identifies knowledge gaps and directions for future research.

The impact of frailty on in-hospital complications in elderly patients with acute coronary syndrome

BACKGROUND

Acute coronary syndrome (ACS) is linked to a range of in-hospital complications, and age is recognized as risk factor for adverse events. Discrepancies between physiological and chronological age are explained by frailty. However, the relationship between frailty and in-hospital complications is not clear.

METHODS

Assessment of frailty in patients was carried out using the FRAIL scale. In-hospital complications assessed included, bleeding, infection, arrhythmia, acute kidney injury (AKI), delirium, stroke/transient ischemic attack (TIA), liver injury, hypoglycemia, length of stay in the cardiac care unit (CCU).

RESULTS

Of the 174 patients, frailty was identified in 39.1% and pre-frailty in 29.9%. Frailty was associated with a higher incidence of all types of bleeding (frail vs. robust: 45.5% vs. 16.7%, P < 0.001) and infection (54.4% vs. 11.1%, P < 0.001), including pneumonia/lower respiratory tract infections (LRTI) and urinary tract infections (UTI). Incidence of antibiotic therapy (52.9% vs. 13.0%, P < 0.001), atrial fibrillation (AF) (47.1% vs. 9.3%, P < 0.001), AKI (57.3% vs. 20.4%, P < 0.001), delirium (52.9% vs. 3.7%, P < 0.001), liver injury, were higher in frail patients (17.6% vs. 0, P = 0.001), whilst their length of stay in the CCU was longer (4 days (2-6.5) vs. 2 days (2-3), P < 0.001). Infections, pneumonia/LRTI, antibiotic therapy during hospitalization, the incidence of AF and liver injury were more often in patients with pre-frailty compared to the robust group. After adjustment for potential confounders, frailty remained independently associated with an increased risk of infection (OR: 3.3 [1.6-7.0]), including pneumonia/LRTI (OR: 2.5 [1.1-5.8]) and UTI (OR: 4.8 [1.8-12.5]). Frail individuals had an increased requirement for antibiotic therapy (OR: 3.9 [1.9-8.1]), and greater risk of AF (OR: 3.5 [1.3-9.3]), AKI (OR: 2.6 [1.2-5.3]) delirium (OR: 11.7 [4.8-28.7]), as well as having to stay longer in the CCU (> 3 days) (OR: 3.7 [1.9-7.3]).

CONCLUSIONS

Frailty was associated with an increased risk of numerous in-hospital complications in elderly patients who had been hospitalized with ACS.

Angiographic and Procedural Characteristics in Frail Older Patients with Non-ST Elevation Acute Coronary Syndrome

Background

Angiographic and procedural characteristics stratified by frailty status are not known in older patients with non-ST elevation acute coronary syndrome (NSTEACS). We evaluated angiographic and procedural characteristics in older adults with NSTEACS by frailty category, as well as associations of baseline and residual SYNTAX scores with long-term outcomes.

Methods

In this study, 271 NSTEACS patients aged ≥75 years underwent coronary angiography. Frailty was assessed using the Fried criteria. Angiographic analysis was performed using QAngio® XA Medis in a core laboratory. Major adverse cardiovascular events (MACE) consisted of all-cause mortality, MI, stroke or transient ischaemic attack, repeat unplanned revascularisation and significant bleeding.

Results

Mean (±SD) patient age was 80.5 ± 4.9 years. Compared with robust patients, patients with frailty had more severe culprit lesion calcification (OR 5.40; 95% CI [1.75-16.8]; p=0.03). In addition, patients with frailty had a smaller mean improvement in culprit lesion stenosis after percutaneous coronary intervention (50.6%; 95% CI [45.7-55.6]) than robust patients (58.6%; 95% CI [53.5-63.7]; p=0.042). There was no association between frailty phenotype and completeness of revascularisation (OR 0.83; 95% CI [0.36-1.93]; p=0.67). A high baseline SYNTAX score (≥33) was associated with adjusted (age and sex) 5-year MACE (HR 1.40; 95% CI [1.08-1.81]; p=0.01), as was a high residual SYNTAX score (≥8; adjusted HR 1.22; 95% CI [1.00-1.49]; p=0.047).

Conclusion

Frail adults presenting with NSTEACS have more severe culprit lesion calcification. Frail adults were just as likely as robust patients to receive complete revascularisation. Baseline and residual SYNTAX score were associated with MACE at 5 years.

The influence of pressure injury risk on the association between left ventricular ejection fraction and all-cause mortality in patients with acute myocardial infarction 80 years or older

BACKGROUND

We aimed to investigate whether the pressure injury risk mediates the association of left ventricular ejection fraction (LVEF) with all-cause death in patients with acute myocardial infarction (AMI) aged 80 years or older.

METHODS

This retrospective cohort study included 677 patients with AMI aged 80 years or older from a tertiary-level hospital. Pressure injury risk was assessed using the Braden scale at admission, and three risk groups (low/minimal, intermediate, high) were defined according to the overall score of six different variables. LVEF was measured during the index hospitalization for AMI. All-cause death after hospital discharge was the primary outcome.

RESULTS

Over a median follow-up period of 1,176 d (interquartile range [IQR], 722-1,900 d), 226 (33.4%) patients died. Multivariate Cox regression analysis showed that reduced LVEF was associated with an increased risk of all-cause death only in the high-risk group of pressure injury (adjusted hazard ratios [HR]=1.81, 95% confidence interval [CI]: 1.03-3.20; P=0.040), but not in the low/minimal- (adjusted HR=1.29, 95%CI: 0.80-2.11; P=0.299) or intermediate-risk groups (adjusted HR=1.14, 95%CI: 0.65-2.02; P=0.651). Significant interactions were detected between pressure injury risk and LVEF (adjusted P=0.003). The cubic spline with hazard ratio plot revealed a distinct shaped curve relation between LVEF and all-cause death among different pressure injury risk groups.

CONCLUSIONS

In older patients with AMI, the risk of pressure injury mediated the association between LVEF and all-cause death. The classification of older patients for both therapy and prognosis assessment appears to be improved by the incorporation of pressure injury risk assessment into AMI care management.

Multiple mediating effects of self-efficacy and physical activity on the relationship between frailty and health-related quality of life in adults with CVD

AIMS

Poor health-related quality of life is prevalent among individuals with cardiovascular disease (CVD) and may be associated with frailty as well as low levels of self-efficacy and physical activity. This study aimed to identify the multiple mediating effects of exercise self-efficacy and physical activity on the relationship between frailty and health-related quality of life among community-dwelling adults with CVD.

METHODS AND RESULTS

This cross-sectional study included 489 Korean patients aged >20 years diagnosed with CVD. Data were collected through an online survey conducted in June, 2021. The mediation hypothesis was tested using a serial multiple mediation model and the bootstrapping method. Approximately 39.5% of patients in this study were in a frail state. Our main finding revealed that frailty had an indirect effect on health-related quality of life through all three different pathways: each single mediation of exercise self-efficacy and physical activity, and the serial multiple mediation of exercise self-efficacy and physical activity as the first and second mediators, respectively. The direct effect of frailty on the health-related quality of life was also significant.

CONCLUSION

Frail adults with CVD tended to have lower levels of self-efficacy, physical activity, and poor health-related quality of life. Thus, early identification of frailty and interventions targeting the promotion of self-efficacy and physical activity may improve health-related quality of life in adults with CVD. Longitudinal studies are necessary to further refine our findings across other samples and to address the limitations of the current study.

Comparing health outcomes between coronary interventions in frail patients aged 75 years or older with acute coronary syndrome: a systematic review

Aim

To assess the current evidence comparing the health outcomes of coronary interventions in frail patients aged 75 years or older with acute coronary syndrome.

Findings

Available studies are observational and limited by incomplete statistical adjustment required for robust causal analysis. There may be a signal for improved outcomes in acute coronary syndrome patients treated invasively vs conservatively.

Message

Robust studies are needed to inform the optimal selection of coronary interventions in frail older patients with acute coronary syndrome.

Purpose

To assess current evidence comparing the impact of available coronary interventions in frail patients aged 75 years or older with different subtypes of acute coronary syndrome (ACS) on health outcomes.

Methods

Scopus, Embase and PubMed were systematically searched in May 2022 for studies comparing outcomes between coronary interventions in frail older patients with ACS. Studies were excluded if they provided no objective assessment of frailty during the index admission, under-represented patients aged 75 years or older, or included patients with non-ACS coronary disease without presenting results for the ACS subgroup. Following data extraction from the included studies, a qualitative synthesis of results was undertaken.

Results

Nine studies met all eligibility criteria. All eligible studies were observational. Substantial heterogeneity was observed across study designs regarding ACS subtypes included, frailty assessments used, coronary interventions compared, and outcomes studied. All studies were assessed to be at high risk of bias. Notably, adjustment for confounders was limited or not adequately reported in all studies. The comparative assessment suggested a possible efficacy signal for invasive treatment relative to conservative treatment but possibly at the risk of increased bleeding events.

Conclusions

There is a paucity of evidence comparing health outcomes between different coronary interventions in frail patients aged 75 years or older with ACS. Available evidence is at high risk of bias. Given the growing importance of ACS in frail patients aged 75 years or older, new studies are needed to inform optimal ACS care for this population. Future studies should rigorously adjust for confounders.

Impact of oral anticoagulation on the association between frailty and clinical outcomes in people with atrial fibrillation: nationwide primary care records on treatment analysis

AIMS

People with atrial fibrillation (AF) frequently live with frailty, which increases the risk of mortality and stroke. This study reports the association between oral anticoagulation (OAC) and outcomes for people with frailty, and whether there is overall net benefit from treatment in people with AF.

METHODS AND RESULTS

Retrospective open cohort electronic records study. Frailty was identified using the electronic frailty index. Primary care electronic health records of 89 996 adults with AF and CHA2DS2-Vasc score of ≥2 were linked with secondary care and mortality data in the Clinical Practice Research Database (CPRD) from 1 January 1998 to 30 November 2018. The primary outcome was a composite of death, stroke, systemic embolism, or major bleeding. Secondary outcomes were stroke, major bleeding, all-cause mortality, transient ischaemic attack, and falls. Of 89 996 participants, 71 256 (79.2%) were living with frailty. The prescription of OAC increased with degree of frailty. For patients not prescribed OAC, rates of the primary outcome increased alongside frailty category. Prescription of OAC was associated with a reduction in the primary outcome for each frailty category [adjusted hazard ratio, 95% confidence interval, no OAC as reference; fit: vitamin K antagonist (VKA) 0.69, 0.64-0.75, direct oral anticoagulant (DOAC) 0.42, 0.33-0.53; mild frailty: VKA 0.52, 0.50-0.54, DOAC 0.57, 0.52-0.63; moderate: VKA 0.54, 0.52-0.56, DOAC 0.57, 0.52-0.63; severe: VKA 0.48, 0.45-0.51, DOAC 0.58, 0.52-0.65], with cumulative incidence function effects greater for DOAC than VKA.

CONCLUSION

Frailty among people with AF is common. The OAC was associated with a reduction in the primary endpoint across all degrees of frailty.

Preexisting frailty and outcomes in older patients with acute myocardial infarction

BACKGROUND

Little is known about the prevalence and prognostic impact of preexisting frailty on acute care and in-hospital outcomes in older adults in the setting of acute myocardial infarction (AMI).

METHODS

Preexisting frailty was assessed at baseline in consecutive AMI patients ≥65 years of age treated at 778 hospitals participating in the NCDR ACTION Registry between January 1, 2015 to December 31, 2016. Three domains of preexisting frailty (cognition, ambulation, and functional independence) were abstracted from chart review and summed in 2 ways: an ACTION Frailty Scale based on responses to 6 groups adapted from the Canadian Study of Health and Aging Clinical Frailty Scale and an ACTION Frailty Score derived by summing a rank score of 0-2 assigned for each grade (total ranged between 0 to 6). Multivariable logistic regression examined the association between assigned frailty by score or scale and in-hospital mortality.

RESULTS

Among 143,722 older AMI patients, 108,059 (75.2%) were fit and/or well and 6,484 (4.5%) were vulnerable to frailty, while 7,527 (5.2%) had mild, 3,913 (2.7%) had moderate, 2,715 had (1.9%) severe, and 632 (0.4%) had very severe frailty according to the ACTION Frailty Scale, while 14,392 (10.0%) could not be categorized due to incomplete ascertainment. Frail patients were older, more frequently female, of non-white race and/or ethnicity, and less likely to be treated with guideline-recommended therapies. Increasing severity of frailty by this scale was associated with a step-wise higher risk for in-hospital mortality (P-trend < .001). Patient categories of the ACTION Frailty Score provided similar results. After adjustment, each 1-unit increase in Frailty Score was associated with a 12% higher mortality risk (OR 1.12, 95% CI 1.10-1.15).

CONCLUSIONS

Among older patients with acute myocardial infarction, frailty is common and independently associated with in-hospital mortality. These findings show the importance of pragmatic evaluation of frailty in hospital-level quality scores, guideline recommendations, and incorporation into other registry data collection efforts.

Braden Skin Score Subdomains Predict Mortality Among Cardiac Intensive Care Patients

BACKGROUND

The Braden Skin Score (BSS) is a bedside nursing assessment that may be a measure of frailty and predicts mortality among patients in the cardiac intensive care unit (CICU). We examined the association between each of the 6 individual BSS subscores with hospital mortality in patients in the CICU. We hypothesized that BSS subscores reflecting patient frailty would have a stronger association with outcomes.

METHODS

Retrospective cohort study of unique adult patients admitted to the Mayo Clinic CICU from 2007 to 2018 with BSS documented on admission. Primary outcome was all-cause hospital mortality. Odds ratios (ORs) were determined using multivariable logistic regression.

RESULTS

The 11,954 included patients had a mean age of 67.4 ± 15.2 years (37.8% women). Each individual BSS subscore was lower among patients who died in the hospital (all P < .001). The total BSS was inversely associated with in-hospital mortality across admission diagnoses and among patients with coma or mechanical ventilation; each individual subscore was inversely associated with in-hospital mortality. On multivariable regression, all subscores were inversely associated with hospital mortality after full adjustment. Shear had the strongest association (adjusted OR 0.59), followed by nutrition (adjusted OR 0.67), skin moisture (adjusted OR 0.76), mobility (adjusted OR 0.76), sensory perception (adjusted OR 0.82), and activity level (adjusted OR 0.85).

CONCLUSION

BSS can serve as a rapid noninvasive screening tool for identifying poor outcomes in patients in the CICU. BSS subdomains that are more strongly associated with mortality appear to reflect physical frailty. Insofar as the BSS and its subscores measure frailty, a low BSS may identify frail patients.

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.

Perceived vs. objective frailty in patients with atrial fibrillation and impact on anticoagulant dosing: an ETNA-AF-Europe sub-analysis

AIMS

Frailty is common in patients with atrial fibrillation (AF), with possible impact on therapies and outcomes. However, definitions of frailty are variable, and may not overlap with frailty perception among physicians. We evaluated the prevalence of frailty as perceived by enrolling physicians in the Edoxaban Treatment in Routine Clinical Practice for Patients With Non-Valvular AF (ETNA-AF)-Europe registry (NCT02944019), and compared it with an objective frailty assessment.

METHODS AND RESULTS

ETNA-AF-Europe is a prospective, multi-centre, post-authorization, observational study. There we assessed the presence of frailty according to (i) a binary subjective investigators' judgement and (ii) an objective measure, the Modified Frailty Index. Baseline data on frailty were available in 13 621/13 980 patients. Prevalence of perceived frailty was 10.6%, with high variability among participating countries and healthcare settings (range 5.9-19.6%). Conversely, only 5.0% of patients had objective frailty, with minimal variability (range 4.5-6.7%); and only <1% of patients were identified as frail by both approaches. Compared with non-frailty-perceived, perceived frail patients were older, more frequently female, and with lower body weight; conversely, objectively frail patients had more comorbidities. Non-recommended edoxaban dose regimens were more frequently prescribed in both frail patient categories.

CONCLUSIONS

Physicians' perception of frailty in AF patients is variable, mainly driven by age, sex, and weight, and quite different compared with the results of an objective frailty assessment. Whatever the approach, frailty appears to be associated with non-recommended anticoagulant dosages. Whether this apparent inappropriateness influences hard outcomes remains to be assessed.

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.

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.

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.

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.

Prevalence and Prognosis Impact of Frailty Among Older Adults in Cardiac Intensive Care Units

Background

Whether frailty, defined as a biological syndrome that reflects a state of decreased physiological reserve and vulnerability to stressors, may impact the outcomes of elderly patients admitted to a cardiac intensive care unit (CICU) remains unclear. We aimed to determine the prevalence of frailty and its impact on mortality in patients aged ≥ 80 years admitted to a CICU.

Methods

This prospective single-centre observational study was conducted among patients aged ≥ 80 years admitted to a CICU in a tertiary centre. Frailty was assessed using the Edmonton Frail Scale (EFS), which provides a score ranging from 0 (not frail) to 17 (very frail). The population was divided into 3 classes: EFS-score of 0-3, EFS-score of 4-6, and EFS-score > 7.

Results

A total of 199 patients were included, and median follow-up duration was 365 days. The mean age was 84.8 years, and 50 patients (25.1%) died during the follow-up period. In all, 45 (22.6%), 60 (30.2%), and 94 patients (47.2%) had an EFS-score of 0-3, 4-6, and ≥ 7, respectively. The all-cause mortality rate was 4.4%, 27.1%, and 37.2% in the 0-3, 4-6, and ≥ 7 EFS-score groups, respectively (P < 0.001). After multivariate analysis, frailty status remained associated with all-cause mortality: hazard ratio was 2.60 (95% confidence interval 0.54-12.45) within the 4-6 EFS-score group, and 5.46 (95% confidence interval 1.23-24.08) within the ≥ 7 EFS-score group.

Conclusions

Frailty is highly prevalent in older adults admitted to the population hospitalized in a CICU and represents a strong prognostic factor for 1-year all-cause mortality.

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.

The degree of frailty as a translational measure of health in aging

Frailty is a multiply determined, age-related state of increased risk for adverse health outcomes. We review how the degree of frailty conditions the development of late-life diseases and modifies their expression. The risks for frailty range from subcellular damage to social determinants. These risks are often synergistic-circumstances that favor damage also make repair less likely. We explore how age-related damage and decline in repair result in cellular and molecular deficits that scale up to tissue, organ and system levels, where they are jointly expressed as frailty. The degree of frailty can help to explain the distinction between carrying damage and expressing its usual clinical manifestations. Studying people-and animals-who live with frailty, including them in clinical trials and measuring the impact of the degree of frailty are ways to better understand the diseases of old age and to establish best practices for the care of older adults.

Effectiveness and Safety of Rivaroxaban by General Practitioners - A Multicenter, Prospective Study in Japanese Patients With Non-Valvular Atrial Fibrillation (GENERAL)

BACKGROUND

Direct oral anticoagulants have become a standard therapy for non-valvular atrial fibrillation (NVAF). However, little is known about their effectiveness/safety when prescribed by general practitioners to treat high-risk populations such as the elderly, those who are frail or have cognitive dysfunction.

METHODS AND RESULTS

In this multicenter, prospective study, a total of 5,717 NVAF patients (mean age 73.9 years) receiving rivaroxaban were registered by general practitioners, with a maximum 3-year follow up (mean 2.0±0.5 years). The primary endpoint was a composite of stroke and systemic embolism (SE). The annual incidence (per 100 person-years) of stroke/SE was 1.23% and for major bleeding, it was 0.63%. Multivariate analyses identified age ≥75 years (hazard ratio [HR]; 2.67, P<0.001) and history of ischemic stroke (HR; 1.89, P=0.005) as significant risk factors of stroke/SE, with history of major bleeding (HR; 14.9, P<0.001) and warfarin use (HR; 2.15, P=0.002) as risk factors for major bleeding events. Neither cognitive dysfunction, defined by the receipt of anti-dementia medications, nor frailty, evaluated by the classification of the Japanese Long-term Care Insurance system, correlated with stroke/SE or major bleeding events.

CONCLUSIONS

The low incidence of adverse events, including stroke/SE and bleeding, in patients prescribed rivaroxaban by general practitioners supports its use as a safe and efficacious treatment in the standard clinical care of high-risk patient populations.

Admission Braden Scale Score as an Early Independent Predictor of In-Hospital Mortality Among Inpatients With COVID-19: A Retrospective Cohort Study

Background

The COVID‐19 pandemic has put a strain on health systems. Predictors of adverse outcomes need to be investigated to properly manage COVID‐19 patients. The Braden Scale (BS), commonly used for the assessment of pressure ulcer risk, has recently been proposed to identify frailty.

Objective

To investigate the predictive utility of the BS for prediction of in‐hospital mortality in a cohort of COVID‐19 patients admitted to non‐ICU wards.

Methods

We conducted a retrospective single‐center cohort study evaluating all patients with SARS‐CoV‐2 infection consecutively admitted over a 2‐month period (from March 6 to May 7, 2020) to the COVID‐19 general wards of our institution. Demographic, clinical, and nursing assessment data, including admission BS, were extracted from electronic medical records. Univariable and multivariable logistic regression models were used to explore the association between the BS score and in‐hospital death.

Results

Braden Scale was assessed in 146 patients (mean age 74.7 years; 52% males). On admission, 46 had a BS ≤ 15, and 100 patients had a BS > 15. Mortality among patients with BS ≤ 15 was significantly higher than in patients with BS > 15 (45.7% vs. 16%; p < .001). On multivariable regression analysis, adjusting for potentials confounders (age, Barthel scale, chronic kidney disease, atrial fibrillation, and hypertension), the admission BS remained inversely associated with the risk of in‐hospital mortality (OR = 0.76; 95% CI [0.60, 0.96]; p = .020).

Linking Evidence to Action

Admission BS could be used as a simple bedside predictive tool able to early identify non‐ICU COVID‐19 patients with poor prognosis who might benefit from specific and timely interventions.

Cardiac Rehabilitation in Frail Older Adults With Cardiovascular Disease: A NEW DIAGNOSTIC AND TREATMENT PARADIGM

Older adults with cardiovascular disease (CVD) pose challenges to cardiac rehabilitation (CR) clinicians because their disease is often coupled to physical frailty. Older patients with CVD and frailty may be less likely to tolerate conventional CR exercise training due to multidimensional (ie, strength, mobility, and balance) physical impairments. Furthermore, conventional CR typically emphasizes endurance training without addressing the intrinsic skeletal muscle impairments of frail patients that often manifest as deficits in strength, mobility, and balance, undercutting feasibility and any likely benefits. However, if appropriately modified to meet the needs of frail older adults, CR may be a powerful tool for this challenging population. To best serve frail, older adults with CVD, CR programs can incorporate well-validated strategies to assess frailty and physical function that also fit within the workflows and patient populations of individual programs. Such frailty assessments provide opportunities to identify specific targets (eg, weakness) that need to be addressed before a subsequent aerobic training program can be successfully implemented and sustained. The current review focuses on the use of physical frailty measures in older adults with CVD, with practical considerations for their clinical use in contemporary CR, as well as directions for future research.

'You can't start a car when there's no petrol left': a qualitative study of patient, family and clinician perspectives on implantable cardioverter defibrillator deactivation

OBJECTIVE

To explore the attitudes towards implantable cardioverter defibrillator (ICD) deactivation and initiation of deactivation discussions among patients, relatives and clinicians.

DESIGN

A multiphase qualitative study consisting of in situ hospital ICD clinic observations, and semistructured interviews of clinicians, patients and relatives. Data were analysed using a constant comparative approach.

SETTING

One tertiary and two district general hospitals in England.

PARTICIPANTS

We completed 38 observations of hospital consultations prior to ICD implantation, and 80 interviews with patients, family members and clinicians between 2013 and 2015. Patients were recruited from preimplantation to postdeactivation. Clinicians included cardiologists, cardiac physiologists, heart failure nurses and palliative care professionals.

RESULTS

Four key themes were identified from the data: the current status of deactivation discussions; patients' perceptions of deactivation; who should take responsibility for deactivation discussions and decisions; and timing of deactivation discussions. We found that although patients and doctors recognised the importance of advance care planning, including ICD deactivation at an early stage in the patient journey, this was often not reflected in practice. The most appropriate clinician to take the lead was thought to be dependent on the context, but could include any appropriately trained member of the healthcare team. It was suggested that deactivation should be raised preimplantation and regularly reviewed. Identification of trigger points postimplantation for deactivation discussions may help ensure that these are timely and inappropriate shocks are avoided.

CONCLUSIONS

There is a need for early, ongoing and evolving discussion between ICD recipients and clinicians regarding the eventual need for ICD deactivation. The most appropriate clinician to instigate deactivation discussions is likely to vary between patients and models of care. Reminders at key trigger points, and routine discussion of deactivation at implantation and during advance care planning could prevent distressing experiences for both the patient and their family at the end of life.

Association between frailty and ischemic heart disease: a systematic review and meta-analysis

Background

Frailty is increasingly reported among older adults with cardiovascular diseases and it has been demonstrated to increase negative health outcomes and mortality. To date, no systematic review of the evidence is available regarding the association between frailty and ischemic heart disease (IHD). We performed a systematic review of literature and a meta-analysis to assess the association between frailty and IHD.

Methods

We selected all the studies that provided information on the association between frailty and IHD, regardless of the study setting, study design, or definition of IHD and frailty. PubMed, Web of Science and Embase were searched for relevant papers. Studies that adopted the Fried definition for frailty were included in the meta-analyses. For each measure of interest (proportions and estimates of associations), a meta-analysis was performed if at least three studies used the same definition of frailty. Pooled estimates were obtained through random effect models and Mantel-Haenszel weighting.

Results

Thirty-seven studies were included. Of these, 22 adopted the Fried criteria to define frailty and provided estimates of prevalence and therefore they were included in meta-analyses. The pooled prevalence of IHD in frail individuals was 17% (95% Confidence Interval [95%CI] 11–23%) and the pooled prevalence of frailty in individuals with IHD was 19% (95% CI 15–24%). The prevalence of frailty among IHD patients ranged from 4 to 61%. Insufficient data were found to assess longitudinal association between frailty and IHD.

Conclusions

Frailty is quite common in older persons with IHD. The identification of frailty among older adults with IHD should be considered relevant to provide individualized strategies of cardiovascular prevention and care. Further research should specifically explore the association between frailty and IHD and investigate the potential common biological ground.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12877-021-02304-9.

Comprehensive geriatric assessment in elderly and senile patients with cardiovascular diseases. Expert opinion of the Russian Association of Gerontologists and Geriatricians

Senile asthenia syndrome (SAS) is a geriatric syndrome characterized by age-associated decline of the physiological reserve and function in multiple systems, which results in higher vulnerability to effects of endo- and exogenous factors and a high risk of unfavorable outcomes, loss of self-sufficiency, and death. Generally, SAS is observed in elderly patients with comorbidities. In cardiovascular diseases, SAS is associated with a poor prognosis, including a higher incidence of exacerbation and death both during acute events and in chronic disease. However, SAS is often not taken into account in developing diagnostic and therapeutic programs for managing elderly patients with cardiovascular diseases (CVD). This article analyzes available scientific information about SAS, algorithms for SAS diagnosis, and the scales that may be useful in developing individual plans for management of elderly patients with CVD.

Risk stratification scores for patients with acute heart failure in the Emergency Department: A systematic review

AIMS

This study aimed to systematically identify and summarise all risk scores evaluated in the emergency department setting to stratify acute heart failure patients.

METHODS AND RESULTS

A systematic review of PubMed and Web of Science was conducted including all multicentre studies reporting the use of risk predictive models in emergency department acute heart failure patients. Exclusion criteria were: (a) non-original articles; (b) prognostic models without predictive purposes; and (c) risk models without consecutive patient inclusion or exclusively tested in patients admitted to a hospital ward. We identified 28 studies reporting findings on 19 scores: 13 were originally derived in the emergency department (eight exclusively using acute heart failure patients), and six in emergency department and hospitalised patients. The outcome most frequently predicted was 30-day mortality. The performance of the scores tended to be higher for outcomes occurring closer to the index acute heart failure event. The eight scores developed using acute heart failure patients only in the emergency department contained between 4-13 predictors (age, oxygen saturation and creatinine/urea included in six scores). Five scores (Emergency Heart Failure Mortality Risk Grade, Emergency Heart Failure Mortality Risk Grade 30 Day mortality ST depression, Epidemiology of Acute Heart Failure in Emergency department 3 Day, Acute Heart Failure Risk Score, and Multiple Estimation of risk based on Emergency department Spanish Score In patients with Acute Heart Failure) have been externally validated in the same country, and two (Emergency Heart Failure Mortality Risk Grade and Multiple Estimation of risk based on Emergency department Spanish Score In patients with Acute Heart Failure) further internationally validated. The c-statistic for Emergency Heart Failure Mortality Risk Grade to predict seven-day mortality was between 0.74-0.81 and for Multiple Estimation of risk based on Emergency department Spanish Score In patients with Acute Heart Failure to predict 30-day mortality was 0.80-0.84.

CONCLUSIONS

There are several scales for risk stratification of emergency department acute heart failure patients. Two of them are accurate, have been adequately validated and may be useful in clinical decision-making in the emergency department i.e. about whether to admit or discharge.

Atrial fibrillation and oral anticoagulation in older people with frailty: a nationwide primary care electronic health records cohort study

BACKGROUND

Atrial fibrillation (AF) is common in older people and is associated with increased stroke risk that may be reduced by oral anticoagulation (OAC). Frailty also increases with increasing age, yet the extent of OAC prescription in older people according to extent of frailty in people with AF is insufficiently described.

METHODS

An electronic health records study of 536,955 patients aged ≥65 years from ResearchOne in England (384 General Practices), over 15.4 months, last follow-up 11th April 2017. OAC prescription for AF with CHA2DS2-Vasc ≥2, adjusted (demographic and treatments) risk of all-cause mortality, and subsequent cerebrovascular disease, bleeding and falls were estimated by electronic frailty index (eFI) category of fit, mild, moderate and severe frailty.

RESULTS

AF prevalence and mean CHA2DS2-Vasc for those with AF increased with increasing eFI category (fit 2.9%, 2.2; mild 11.2%, 3.2; moderate 22.2%, 4.0; and severe 31.5%, 5.0). For AF with CHA2DS2-Vasc ≥2, OAC prescription was higher for mild (53.2%), moderate (55.6%) and severe (53.4%) eFI categories than fit (41.7%). In those with AF and eligible for OAC, frailty was associated with increased risk of death (HR for severe frailty compared with fit 4.09, 95% confidence interval 3.43-4.89), gastrointestinal bleeding (2.17, 1.45-3.25), falls (8.03, 4.60-14.03) and, among women, stroke (3.63, 1.10-12.02).

CONCLUSION

Among older people in England, AF and stroke risk increased with increasing degree of frailty; however, OAC prescription approximated 50%. Given competing demands of mortality, morbidity and stroke prevention, greater attention to stratified stroke prevention is needed for this group of the population.

Frailty implications for exercise participation and outcomes in patients with heart failure

BACKGROUND/OBJECTIVES

Frailty is common in people with heart failure (HF) and associated with poorer outcomes. The aim of this study was to describe the characteristics, exercise participation, and outcomes of frail and not-frail participants enrolled in a randomized trial of exercise training (ET) within a cardiac rehabilitation (CR) program.

DESIGN

Secondary analysis of EJECTION-HF randomized trial (ACTRN12608000263392).

SETTING

Five HF-specific CR programs in Queensland, Australia.

PARTICIPANTS

Adults recently hospitalized with HF.

INTERVENTION

All participated in CR including home exercise prescription and monitoring; half were randomized to center-based ET.

MEASUREMENTS

A frailty index (FI) was constructed at randomization and 6-month follow-up. Outcomes included ET attendance, change in 6-min walk distance (6MWD), improved FI (>0.09 units) at 6 months, achieving physical activity (PA) guidelines at 6 months, and 12 month all-cause death or readmission.

RESULTS

The FI was measured in 256 participants at randomization: 110 (43%) were not-frail (FI 0.2 or less), 119 (46%) were frail (FI >0.2 to 0.39), and 27 (11%) were very frail (FI ≥0.4). Frailty was more common with older age, female gender, decompensated HF, worse HF symptoms, and preserved ejection fraction. ET attendance did not differ by frailty group. Participants who were more frail had lower 6WMD at enrollment, but similar improvement over 6 months. Mean FI improved by 0.03 units at 6 months (95% CI 0.02-0.04, p < 0.001). Participants who were more frail had significantly greater improvements in FI compared with not-frail participants and were often able to achieve PA guidelines, both in intervention and control groups. Neither baseline frailty nor intervention was significantly associated with 12-month death or readmission.

CONCLUSION

Frail people with HF participating in CR that includes home and/or center-based ET often achieve PA guidelines, and some may have meaningful reductions in frailty.

Frailty Scores and Their Utility in Older Patients with Cardiovascular Disease

The world’s population is ageing, resulting in more people with frailty receiving treatment for cardiovascular disease (CVD). The emergence of novel interventions, such as transcatheter aortic valve implantation, has also increased the proportion of older patients being treated in later stages of life. This increasing population burden makes the assessment of frailty of utmost importance, especially in patients with CVD. Despite a growing body of evidence on the association between frailty and CVD, there is no consensus on the optimal frailty assessment tool for use in clinical settings. Previous studies have shown limited concordance between validated frailty instruments. This review evaluates the evidence on the utility of frailty assessment tools in patients with CVD, and the effect of frailty on different outcomes measured.

Randomized Comparison of Exercise Intervention Versus Usual Care in Older Adult Patients with Frailty After Acute Myocardial Infarction

BACKGROUND

Older adult patients with frailty are rarely involved in rehabilitation programs after myocardial infarction. Our aim was to investigate the benefits of exercise intervention in these patients.

METHODS

A total of 150 survivors after acute myocardial infarction, ≥70 years and with pre-frailty or frailty (Fried scale ≥1 points), were randomized to control (n = 77) or intervention (n = 73) groups. The intervention consisted of a 3-month exercise program, under physiotherapist supervision, followed by an independent home-based program. The main outcome was frailty (Fried scale) at 3 months and 1 year. Secondary endpoints were clinical events (mortality or any readmission) at 1 year.

RESULTS

Mean age was 80 years (range = 70-96). In the intervention group, 44 (60%) out of 73 patients participated in the program and 23 (32%) completed it. Overall, there was a decrease in the Fried score in the intervention group at 3 months, with no effect at 1 year. However, in the intention-to-treat analysis, such change did not achieve statistical significance (P = 0.110). Only treatment comparisons made among the subgroups that participated in (P = 0.033) and completed (P = 0.018) the program achieved statistical significance. There were no differences in clinical events. Worse Fried score trajectory along follow-up increased mortality risk (hazard ratio [HR] = 2.38, 95% confidence interval [CI] 1.24-4.55, P = 0.009) CONCLUSIONS: Recruitment and retention for a physical program in older adult patients with frailty after myocardial infarction was challenging. Frailty status improved in the subgroup that participated in the program, although this benefit was attenuated after shifting to a home-based program. A better frailty trajectory might influence midterm prognosis. (ClinicalTrials.govNCT02715453).

Clinical outcomes in patients with atrial fibrillation and frailty: insights from the ENGAGE AF-TIMI 48 trial

BACKGROUND

Atrial fibrillation (AF) is common in older people with frailty and is associated with an increased risk of stroke and systemic embolism. Whilst oral anticoagulation is associated with a reduction in this risk, there is a lack of data on the safety and efficacy of direct oral anticoagulants (DOACs) in people with frailty. This study aims to report clinical outcomes of patients with AF in the Effective Anticoagulation with Factor Xa Next Generation in Atrial Fibrillation-Thrombolysis in Myocardial Infarction 48 (ENGAGE AF-TIMI 48) trial by frailty status.

METHODS

Post hoc analysis of 20,867 participants in the ENGAGE AF-TIMI 48 trial, representing 98.8% of those randomised. This double-blinded double-dummy trial compared two once-daily regimens of edoxaban (a DOAC) with warfarin. Participants were categorised as fit, living with pre-frailty, mild-moderate, or severe frailty according to a standardised index, based upon the cumulative deficit model. The primary efficacy endpoint was stroke or systemic embolism and the safety endpoint was major bleeding.

RESULTS

A fifth (19.6%) of the study population had frailty (fit: n = 4459, pre-frailty: n = 12,326, mild-moderate frailty: n = 3722, severe frailty: n = 360). On average over the follow-up period, the risk of stroke or systemic embolism increased by 37% (adjusted HR 1.37, 95% CI 1.19-1.58) and major bleeding by 42% (adjusted HR 1.42, 1.27-1.59) for each 0.1 increase in the frailty index (four additional health deficits). Edoxaban was associated with similar efficacy to warfarin in every frailty category, and a lower risk of bleeding than warfarin in all but those living with severe frailty.

CONCLUSIONS

Edoxaban was similarly efficacious to warfarin across the frailty spectrum and was associated with lower rates of bleeding except in those with severe frailty. Overall, with increasing frailty, there was an increase in stroke and bleeding risk. There is a need for high-quality, frailty-specific population randomised control trials to guide therapy in this vulnerable population.

TRIAL REGISTRATION

ClinicalTrials.gov NCT00781391 . First registered on 28 October 2008.