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Revascularization in Frail Patients With ACS
Quick Takes
- Intermediate and high frailty risk patients presenting with ACS have a reduced likelihood of having echocardiography, invasive angiography, or revascularization performed.
- One year after the index ACS encounter, revascularization patients with a higher frailty risk had a higher absolute reduction in CV mortality compared with low frailty risk.
Study Questions:
Is revascularization beneficial for patients presenting with acute coronary syndrome (ACS) and at higher risk for frailty?
Methods:
This retrospective study performed in England used the Hospital Episode Statistics national database to identify patients diagnosed with an index ACS International Classification of Diseases (ICD) code between 2010 and 2015. Revascularization was defined as either percutaneous coronary intervention (PCI) or coronary artery bypass grafting (CABG) within 6 months of the index ACS encounter. The frailty ICD code and the Hospital Frailty Risk Score were used to place patients into three groups (low, intermediate, or high risk), which included dementia, cognitive dysfunction, falls, or care dependency. Causal variable analysis was performed between risk groups to determine the average short- and long-term treatment effects of revascularization on CV mortality at 1- and 5-year post-index ACS.
Results:
Among the 565,378 patients diagnosed with ACS, 11.6% (n = 65,522) were at an intermediate risk and 4.7% (n = 26,504) were at a high risk of frailty. Low risk frailty patients were younger compared to intermediate and high frailty risk patients (median age 70 vs. 81 vs. 84 years, respectively). Compared to low frailty risk patients, the intermediate and high frailty risk patients had a reduced likelihood of having an echocardiography (44.4% vs. 35.8% vs. 29.6%, p < 0.001, respectively), invasive angiography (65.8% vs. 27% vs. 11.9%, p < 0.001, respectively), PCI (40.3% vs. 13.4% vs. 5.9%, p < 0.001, respectively), or CABG (6.3% vs. 1.8% vs. 0.4%, p < 0.001, respectively). High risk frailty patients received medical management alone (93.7%) compared with 53% of low risk frailty patients.
Death related to CV events at 5 years was 78.6%, 77.3%, and 75.7% in the low, intermediate, and high frailty risk patients, respectively. Revascularization resulted in a higher absolute reduction in CV mortality in the high and intermediate frailty risk patients compared with the low frailty risk patients at 1 year post-ACS (20% and 22% vs.13%, respectively). However, at 5 years post-revascularization, this CV mortality reduction benefit dropped in the high frailty risk patients compared with the low frailty risk patients (10% vs. 16%, respectively).
Conclusions:
Revascularization is associated with short- and long-term CV benefits in patients at intermediate and high risk of frailty.
Perspective:
Although frail patients commonly experience CV events, they may often be excluded from clinical trials due to mobility issues or comorbidities. This study showed CV survival benefits for higher frailty risk patients with ACS, which can be used when counseling patients and their caregivers regarding their frailty risk, the potential benefits for medical versus invasive revascularization, and their perceived expectations for quality of life.
Clinical Topics: Acute Coronary Syndromes, Cardiac Surgery, Geriatric Cardiology, Invasive Cardiovascular Angiography and Intervention, Interventions and ACS, Cardiovascular Care Team
Keywords: Acute Coronary Syndrome, Frail Elderly, Myocardial Revascularization
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