Prognosis Impact of Frailty Assessed by the Edmonton Frail Scale in the Setting of Acute Coronary Syndrome in the Elderly

Stroke and frailty index: a two-sample Mendelian randomisation study

INTRODUCTION

Previous observational studies have found an increased risk of frailty in patients with stroke. However, evidence of a causal relationship between stroke and frailty is scarce. The aim of this study was to investigate the potential causal relationship between stroke and frailty index (FI).

METHODS

Pooled data on stroke and debility were obtained from genome-wide association studies (GWAS).The MEGASTROKE Consortium provided data on stroke (N = 40,585), ischemic stroke (IS,N = 34,217), large-vessel atherosclerotic stroke (LAS,N = 4373), and cardioembolic stroke (CES,N = 7 193).Summary statistics for the FI were obtained from the most recent GWAS meta-analysis of UK BioBank participants and Swedish TwinGene participants of European ancestry (N = 175,226).Two-sample Mendelian randomization (MR) analyses were performed by inverse variance weighting (IVW), weighted median, MR-Egger regression, Simple mode, and Weighted mode, and heterogeneity and horizontal multiplicity of results were assessed using Cochran's Q test and MR-Egger regression intercept term test.

RESULTS

The results of the current MR study showed a significant correlation between stroke gene prediction and FI (odds ratio 1.104, 95% confidence interval 1.064 - 1.144, P < 0.001). In terms of stroke subtypes, IS (odds ratio 1.081, 95% confidence interval 1.044 - 1.120, P < 0.001) and LAS (odds ratio 1.037, 95% confidence interval 1.012 - 1.062, P = 0.005). There was no causal relationship between gene-predicted CES and FI. Horizontal multidimensionality was not found in the intercept test for MR Egger regression (P > 0.05), nor in the heterogeneity test (P > 0.05).

CONCLUSIONS

This study provides evidence for a causal relationship between stroke and FI and offers new insights into the genetic study of FI.

Impairments identified by comprehensive geriatric assessment in potential candidates for left ventricular assist device and heart transplantation

Background

The aim of this study was to assess the prevalence of frailty and other impairments in potential left ventricular assist device (LVAD) and heart transplantation (HTx) candidates by performing a preoperative comprehensive geriatric assessment (CGA) and reviewing the treatment recommendations resulting from the CGA.

Methods and results

This cross-sectional study included 73 patients aged ≥40 years who received a CGA as part of the patient selection procedure for LVAD and HTx. In every patient, a conclusion comprising frailty and other impairments was formulated based on the medical, mental, functional, and social domains and recommendations were made. The mean age was 58 years (range 40-71) and 70 % were male. In 97 % of patients, at least one impairment was identified by the CGA. The most common impairments were polypharmacy, high morbidity burden, reduced renal function, osteopenia, depression, poor quality of life, reduced functionality, (risk of) malnutrition, reduced grip strength and high caregiver burden. A small proportion of the potential LVAD and HTx candidates were frail (7 % according to Fried's frailty criteria, 6 % according to the Edmonton Frail Scale) and 39 % were pre-frail. The domains for which most impairments were found and the domains for which most treatment recommendations were given matched well, with the functional domain as the frontrunner.

Conclusion

This study showed that most of the potential candidates for LVAD or HTx have impairments on at least one domain of the CGA. Impairments and associated risks can contribute to the decision making process for candidacy for LVAD and HTx.

Association of Frailty with Adverse Outcomes in Patients with Critical Acute Myocardial Infarction: A Retrospective Cohort Study

Background

Frailty is a risk factor for acute myocardial infarction (AMI). This study examined the association between the modified frailty index (MFI) and adverse outcomes in patients with critical AMI.

Methods

Data were obtained from the Medical Information Mart for Intensive Care IV database. Logistic and Cox regression models and a competing risk model were applied.

Results

Of 5003 patients, 1496 were non-frail and 3507 were frail. Frailty was significantly associated with in-hospital mortality (per point, OR 1.13, 95% CI: 1.05-1.21; frail vs non-frail, OR 1.31, 95% CI: 1.04-1.65) and 1-year mortality (per point, HR 1.15, 95% CI: 1.11-1.20; frail vs non-frail, HR 1.37, 95% CI: 1.20-1.58). Frailty was significantly associated with post-discharge care needs (per point, OR 1.23, 95% CI: 1.14-1.33; frail vs non-frail, OR 1.47, 95% CI: 1.22-1.78). In the competing risk models, frailty was significantly associated with a lower probability of being discharged from the ICU (per point, HR 0.87, 95% CI: 0.85-0.90; frail vs non-frail, HR 0.73, 95% CI: 0.68-0.79) and hospital (per point, HR 0.82, 95% CI: 0.80-0.85; frail vs non-frail, HR 0.62, 95% CI: 0.57-0.68). Subgroup analyses showed the association of frailty with in-hospital and 1-year mortality was stronger in patients with a SOFA score ≤2 than in those with a SOFA score >2 (both p<0.05 for interaction).

Conclusion

Frailty assessed by the MFI was an independent predictor of adverse outcomes in patients with critical AMI and may be helpful for prognostic risk stratification.

Association between frailty and short- and long-term mortality in patients with critical acute myocardial infarction: Results from MIMIC-IV

Background

Frailty has been recognized as an important prognostic indicator in patients with acute myocardial infarction (AMI). However, no study has focused on critical AMI patients. We aimed to determine the impact of frailty on short- and long-term mortality risk in critical AMI patients.

Methods

Data from the Medical Information Mart for Intensive Care (MIMIC)-IV database was used. Frailty was assessed using the Hospital Frailty Risk Score (HFRS). Outcomes were in-hospital mortality and 1-year mortality. Logistic regression and Cox proportional-hazards models were used to investigate the association between frailty and outcomes.

Results

Among 5,003 critical AMI patients, 2,176 were non-frail (43.5%), 2,355 were pre-frail (47.1%), and 472 were frail (9.4%). The in-hospital mortality rate was 13.8%, and the 1-year mortality rate was 29.5%. In our multivariable model, frailty was significantly associated with in-hospital mortality [odds ratio (OR) = 1.30, 95% confidence interval (CI): 1.20-1.41] and 1-year mortality [hazard ratio (HR) = 1.29, 95% CI: 1.24-1.35] as a continuous variable (per five-score increase). When assessed as categorical variables, pre-frailty and frailty were both associated with in-hospital mortality (OR = 2.80, 95% CI: 2.19-3.59 and OR = 2.69, 95% CI: 1.93-3.73, respectively) and 1-year mortality (HR = 2.32, 95% CI: 2.00-2.69 and HR = 2.81, 95% CI: 2.33-3.39, respectively) after adjustment for confounders. Subgroup analysis showed that frailty was only associated with in-hospital mortality in critically ill patients with non-ST-segment elevation myocardial infarction (STEMI) but not STEMI (p for interaction = 0.012). In addition, frailty was associated with 1-year mortality in both STEMI and non-STEMI patients (p for interaction = 0.447). The addition of frailty produced the incremental value over the initial model generated by baseline characteristics for both in-hospital and 1-year mortality.

Conclusion

Frailty, as assessed by the HFRS, was associated with both in-hospital and 1-year mortality in critical AMI patients. Frailty improves the prediction of short- and long-term mortality in critical AMI patients and may have potential clinical applications.

Frailty index based on laboratory tests improves prediction of short-and long-term mortality in patients with critical acute myocardial infarction

Background

Previous studies have shown that the frailty index based on laboratory tests (FI-Lab) can identify older adults at increased risk of adverse health outcomes. This study aimed to determine whether the FI-Lab is associated with mortality risk and can provide incremental improvements in risk stratification of patients with critical acute myocardial infarction (AMI).

Materials and methods

We conducted a secondary analysis of data from the Medical Information Mart for Intensive Care (MIMIC)-IV database. A 33-item FI-Lab was constructed. Outcomes of interest were in-hospital and 1-year mortality. Logistic regression models were used to investigate the association between the FI-Lab and outcomes. For the assessment of the incremental predictive value, the FI-Lab was added to several risk stratification scoring systems for critically ill patients, and the following indices were calculated: Δ C-statistic, integrated discrimination improvement (IDI), and net reclassification improvement (NRI).

Results

Out of 2,159 patients, 477 died in hospital (22.1%), and 898 died during the 1-year follow-up period. After adjustment for confounders, the FI-Lab was associated with increased in-hospital mortality [odds ratio (OR) = 1.06, 95% confidence interval (CI): 1.05-1.07] and 1-year mortality (OR = 1.05, 95% CI: 1.04-1.06) when assessed as a continuous variable (per 0.01-score increase). When assessed as a categorical variable, the FI-Lab was associated with in-hospital mortality (2nd Quartile: OR = 1.89, 95% CI: 1.18-3.03; 3rd Quartile: OR = 3.46, 95% CI: 2.20-5.46; and 4th Quartile: OR = 5.79, 95% CI: 3.61-9.28 compared to 1st Quartile) as well as 1-year mortality (2nd Quartile: OR = 1.66, 95% CI: 1.23-2.24; 3rd Quartile: OR = 2.40, 95% CI: 1.76-3.26; and 4th Quartile: OR = 3.76, 95% CI: 2.66-5.30 compared to 1st Quartile) after adjustment for confounders. The addition of the FI-Lab to all disease severity scores improved discrimination and significantly reclassified in-hospital and 1-year mortality risk.

Conclusion

The FI-Lab was a strong predictor of short- and long-term mortality in patients with critical AMI. The FI-Lab improved the ability to predict mortality in patients with critical AMI and therefore might be useful in the clinical decision-making process.

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.

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.

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.

Cardiovascular care of older adults

Age is an independent risk factor for cardiovascular disease. With the accelerated growth of the population of older adults, geriatric and cardiac care are becoming increasingly entwined. Although cardiovascular disease in younger adults often occurs as an isolated problem, it is more likely to occur in combination with clinical challenges related to age in older patients. Management of cardiovascular disease is transmuted by the context of multimorbidity, frailty, polypharmacy, cognitive dysfunction, functional decline, and other complexities of age. This means that additional insight and skills are needed to manage a broader range of relevant problems in older patients with cardiovascular disease. This review covers geriatric conditions that are relevant when treating older adults with cardiovascular disease, particularly management considerations. Traditional practice guidelines are generally well suited for robust older adults, but many others benefit from a relatively more personalized therapeutic approach that allows for a range of medical circumstances and idiosyncratic goals of care. This requires weighing of risks and benefits amidst the patient's aggregate clinical status and the ability to communicate effectively about this with patients and, where appropriate, their care givers in a process of shared decision making. Such a personalized approach can be particularly gratifying, as it provides opportunities to optimize an older patient's function and quality of life at a time in life when these often become foremost therapeutic priorities.

Baseline CHA2 DS2 -VASc score and prognosis in octogenarians with non-ST segment elevation acute coronary syndrome

BACKGROUND

CHA₂ DS₂ -VASc Score is widely used to predict thromboembolic risk in patients with Atrial Fibrillation (AF). We sought to study if this score predicts outcomes in elderly patients with Non-ST segment Elevation Acute Coronary Syndromes (NSTEACS).

METHODS

The multicenter LONGEVO-SCA prospective registry included 532 unselected patients with NSTEACS aged ≥80 years. Data to calculate CHA₂ DS₂ -VASc Score were available in 523 patients (98.3%). They were classified according to CHA₂ DS₂ -VASc Score: group 1 (score ≤ 4), and 2 (5-9). We studied outcomes in terms of mortality or readmission at 6 months follow-up.

RESULTS

A total of 266 patients (51%) had a high CHA₂ DS₂ -VASc Score (group 2). They were more often women, with more cardiovascular risk factors, such as hypertension or diabetes mellitus, and history of previous stroke and cardiovascular disease and heart failure (all, P = .001). Geriatric syndromes (Barthel Index, Lawton Brody, cognitive impairment, and frailty) and Charlson Index were worse in this group (all, P = .001). They had poorer clinical status on admission, with worse Killip class and lower left ventricle ejection fraction (all, P = .001), and developed new-onset AF more often during admission (12.4% vs. 6.6%, P = .024). At six months follow-up, patients in group 2 had higher reinfarction, all-cause mortality, and mortality or readmission rates. A CHA₂ DS₂ -VASc Score > 4 was associated with mortality or readmission at 6 months (HR 2.07, P < .001). However, after adjusting for potential confounders, this last association was not significant (P = .175).

CONCLUSIONS

A CHA₂ DS₂ -VASc Score > 4 is present in half of octogenarians with NSTEACS and is associated with poorer outcomes. However, it is not an independent predictor of events and should not replace recommended tools for risk prediction in this setting.

Geriatric Assessment and In-Hospital Economic Cost of Elderly Patients With Acute Coronary Syndromes

BACKGROUND

Elderly patients with acute coronary syndromes (ACS) are at higher risk for complications and health care resources expenditure. No previous study has assessed the specific contribution of frailty and other geriatric syndromes to the in-hospital economic cost in this setting.

METHOD

Unselected patients with ACS aged ≥75 years were prospectively included. A comprehensive geriatric assessment was performed during hospitalisation. Hospitalisation-related cost per patient was calculated with an analytical accountability method, including hospital stay-related expenditures, interventions, and consumption of devices. Expenditure was expressed in Euros (2019). The contribution of geriatric syndromes and clinical factors to the economic cost was assessed with a linear regression method.

RESULTS

A total of 194 patients (mean age 82.6 years) were included. Mean length of hospital stay was 11.3 days. The admission-related economic cost was €6,892.15 per patient. Most of this cost was attributable to hospital length of stay (77%). The performance of an invasive strategy during the admission was associated with economic cost (p=0.008). Of all the ageing-related variables, comorbidity showed the most significant association with economic cost (p=0.009). Comorbidity, disability, nutritional risk, and frailty were associated with the hospital length of stay-related component of the economic cost. The final predictive model of economic cost included age, previous heart failure, systolic blood pressure, Killip class at admission, left main disease, and Charlson index.

CONCLUSIONS

Management of ACS in elderly patients is associated with a significant economic cost, mostly due to hospital length of stay. Comorbidity mostly contributes to in-hospital resources expenditure, as well as the severity of the coronary event.

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.

Invasive versus Conservative Management in Patients ≥85 years presenting with Non-ST Elevation Myocardial Infarction

BACKGROUND

Guidelines recommend early coronary angiography (CA) in patients with non-ST-elevation myocardial infarction (NSTEMI), irrespective of age. However, elderly patients are less likely to be treated according to these guidelines due to their perceived high risk and medical comorbidities. Whether an invasive strategy is associated with improved survival in patients aged ≥85 years remains uncertain due to their exclusion from randomised trials.

METHODS

Consecutive patients aged ≥85 years presenting to a tertiary centre with NSTEMI between 2008-18 were included in this retrospective cohort study. Patients were stratified based on whether they underwent invasive management with CA with a view to revascularisation versus conservative management. The primary outcome was long-term mortality.

RESULTS

Of 7,591 patients with NSTEMI, 1052 patients ≥85years were included. 99(9.4%) patients underwent CA. Those undergoing CA were more likely to be younger, male, live independently, without mobility or cognitive issues (all p<0.01). Overall, 495(47%) patients died during a mean follow-up of 1.3±1 year. On Cox regression, after adjusting for age, pre-morbid functional status, cognition and cardiovascular risk factors, invasive management was the strongest predictor for survival (HR 0.47; 95%CI 0.26-0.85; p=0.01). Invasive management was associated with a trend to increased risk of in-hospital bleeding (6.1% vs 2.6%, p=0.054) with no significant difference in stroke (2.0% vs 3.8%, p=0.37).

CONCLUSION

In patients aged ≥85 years who presented with NSTEMI, invasive management was associated with improved survival without significant differences in bleeding or stroke. A randomised controlled study assessing the efficacy and safety of invasive management in very elderly patients with NSTEMI is warranted. This article is protected by copyright. All rights reserved.

Nutritional domains in frailty tools: Working towards an operational definition of nutritional frailty

Different methods have been proposed for the assessment of the nutritional status in frailty phenotypes. In the present narrative review article, we have summarized the number and specifications of nutritional items in existing frailty tools, in order to develop a possible means of assessment and operational definition of the nutritional frailty phenotype. In six different databases until December 2019, we searched for original articles regarding frailty tools (i.e., scales, indexes, scores, questionnaires, instruments, evaluations, screening, indicators), analyzing each tool regarding nutritional items. We identified 160 articles describing 71 frailty tools. Among the selected frailty tools, 54 were community-based (70 %), 17 hospital-based (22 %), 4 validated in long-term care institutions for older adults (LTCIOA) (5.1 %) and 2 validated in both community- and hospital-based settings, including LTCIOA (2.5 %). Fifty-two of these tools (73 %) included at least one nutritional item. Twenty-two (42 %) reported two or more nutritional items. The items were grouped in the following categories: A) anthropometric measurements, B) laboratory measurements, and C) other nutritional-related measurements. Anthropometric measurements stood out compared to all other items. Nutritional items are included in the majority of frailty tools, strengthening the concept that they may have a direct implication on an increased risk of adverse health-related outcomes in frail subjects. This supports the development of the concept of nutritional frailty as an independent frailty phenotype. Subsequent steps will be to assess the contribution of each nutritional item to a possible operational definition of nutritional frailty and define the items that may best identify this new frailty phenotype.

Is frailty a prognostic factor for adverse outcomes in older patients with acute coronary syndrome?

BACKGROUND

There is very limited guidance in regard to how biological age should be estimated and how different comorbidity conditions influence the benefit-risk ration of interventions. Frailty is an important health-related problem in patients, especially in older adults. It is a reflection of biologic rather than chronologic age; frailty may explain why there remains substantial heterogeneity in clinical outcomes within the older patients' population.

AIMS

We aimed to review the prognostic value of frailty for adverse outcomes in older patients with acute coronary syndrome (ACS).

METHODS

Studies published until December 31, 2018, identified by systematic Medline, Embase, and Cochrane Controlled Register of Trials (CENTRAL) searches were reviewed for the association between frailty and mortality in older patients with ACS. We used the Newcastle-Ottawa Quality Assessment Scale to assess the quality of the included studies. We extracted the information of hazard ratios (HR) and odds ratios (OR) with accompanying 95% confidence intervals (CI), and P values of multivariable analysis. Heterogeneity across studies was determined using the Cochran Q value by Review Manager 5.3.

RESULTS

A total of 11 articles involving 7212 patients were included in this meta-analysis. Two studies (Sujino, Y 2015 and Alonso, S.GL 2016; n = 264) reported that frailty was significantly associated with in-hospital mortality in patients with ACS (range of reported OR between 6.38 and 12.0). We performed a subgroup analysis of the other nine studies based on differences in the follow-up time. Pooled meta-analysis demonstrates that frailty was associated with short-term, medium-term, and long-term mortality (HR = 3.67, 4.09, 1.66). There was no association between frailty and bleeding in older patients with ACS.

CONCLUSIONS

Frailty measured by Canadian Study of Health and Aging Clinical Frailty Scale (CSHA-CFS), the Edmonton Frail Scale (EFS), Fried score, Green scores, frailty instrument from the Survey of Health, Ageing and Retirement in Europe (SHARE-FI) index, and FRAIL (Fatigue, Resistance, Ambulation, Illnesses, Loss of weight) scale, leads to significantly higher mortality rates in older patients with ACS.

Prognostic Value of Braden Scale in Patients With Acute Myocardial Infarction: From the Retrospective Multicenter Study for Early Evaluation of Acute Chest Pain

BACKGROUND

The Braden Scale (BS) is a routine nursing measure used to predict pressure ulcer events; it is recommended as a frailty identification instrument.

OBJECTIVE

We aimed to evaluate the predictive utility of the BS in patients with acute myocardial infarction (AMI) undergoing primary percutaneous coronary intervention.

METHODS

We enrolled 2285 patients with AMI from the Retrospective Multicenter Study for Early Evaluation of Acute Chest Pain. The patients were divided into 3 groups (B1, B2, and B3) according to their BS score (≤12 vs 13-14 vs ≥15). The primary endpoint was all-cause death.

RESULTS

There were 264 (12.0%) all-cause deaths during the median follow-up period of 10.5 (7.9-14.2) months. In-hospital and midterm mortality and other adverse outcomes increased with decreases in the BS score. The Kaplan-Meier survival analysis showed that patients with a lower BS score had a lower cumulative survival rate (P < .001). The multivariate Cox regression analysis showed that a decreased BS score was an independent predictor for all-cause mortality (B2 vs B1: hazard ratio, 0.610; 95% confidence interval, 0.440-0.846; P = .003; B3 vs B1: hazard ratio, 0.345; 95% confidence interval, 0.241-0.493; P < .001).

CONCLUSIONS

The BS at admission may be a useful routine nursing measure to evaluate the prognosis of patients with AMI. The BS may be used to stratify risk at early stages and to identify those who may benefit from further assessment and intervention due to frailty syndrome.

Association of frailty with all-cause mortality and bleeding among elderly patients with acute myocardial infarction: a systematic review and meta-analysis

Background

Frailty is a multidimensional syndrome that reflects the physiological reserve of elderly. It is related to unfavorable outcomes in various cardiovascular conditions. We conducted a systematic review and meta-analysis of the association of frailty with all-cause mortality and bleeding after acute myocardial infarction (AMI) in the elderly.

Methods

We comprehensively searched the databases of MEDLINE and EMBASE from inception to March 2019. The studies that reported mortality and bleeding in AMI patients who were evaluated and classified by frailty status were included. Data from each study were combined using the random-effects, generic inverse variance method of DerSimonian and Laird to calculate hazard ratio (HR), and 95% confidence interval (CI).

Results

Twenty-one studies from 2011 to 2019 were included in this meta-analysis involving 143,301 subjects (mean age 75.33-year-old, 60.0% male). Frailty status was evaluated using different methods such as Fried Frailty Index. Frailty was statistically associated with increased early mortality in nine studies (pooled HR = 2.07, 95% CI: 1.67–2.56, P < 0.001, I² = 41.2%) and late mortality in 11 studies (pooled HR = 2.30, 95% CI: 1.70–3.11, P < 0.001, I² = 65.8%). Moreover, frailty was also statistically associated with higher bleeding in 7 studies (pooled HR = 1.34, 95% CI: 1.12–1.59, P < 0.001, I² = 4.7%).

Conclusion

Frailty is strongly and independently associated with bleeding, early and late mortality in elderly with AMI. Frailty assessment should be considered as an additional risk factor and used to guide toward personalized treatment strategies.

Frailty as a predictor of all-cause mortality and readmission in older patients with acute coronary syndrome : A systematic review and meta-analysis

BACKGROUND

Evidence from longitudinal studies linking frailty and outcome after acute coronary syndrome (ACS) is mixed. This systematic review and meta-analysis aimed to examine whether frailty is a predictor of all-cause mortality and hospital readmission in older patients with ACS.

METHODS

A systematic search was carried out in PubMed, EMBASE and Web of Science databases for studies evaluating the association between frailty and outcomes in older patients with ACS. A meta-analysis was performed to determine the pooled effect estimate for the association between frailty and mortality and hospital readmission, respectively.

RESULTS

A total of 1459 articles were retrieved based on our search strategy. Fifteen studies involving 10,245 patients were included in the meta-analysis. The pooled prevalence of frailty was 32% (95% confidence interval [CI]: 25-39%), and the pooled prevalence of pre-frailty was 33% (95% CI: 26-40%) in elderly patients with ACS. Pooled analyses showed that frailty was associated with significantly higher risk of all-cause mortality and readmission (hazard ratios [HRs] = 2.43 and 2.32, respectively). Pre-frailty was also associated with significantly higher risk of all-cause mortality and readmission, respectively (HRs = 1.55 and 1.34, respectively).

CONCLUSIONS

Both frailty and pre-frailty are risk factors for all-cause mortality and readmission in older patients with ACS. Therefore, frailty assessment should be given sufficient attention in the management of older patients with ACS to help improve survival and reduce readmission rate.

Impact of Diabetes Mellitus and Frailty on Long-Term Outcomes in Elderly Patients with Acute Coronary Syndromes

OBJECTIVES

Diabetes mellitus (DM) and frailty are common in older patients with acute coronary syndromes (ACS). No data exists about its prognostic impact on long-term outcomes and their possible interaction in this setting.

DESIGN

Observational prospective study.

SETTING

Multicenter registry conducted in 44 hospitals in Spain.

PARTICIPANTS

Consecutive patients with ACS aged 80≥years.

MEASUREMENTS

A comprehensive geriatric evaluation was performed during hospitalization, including frailty assessment by the FRAIL score. The impact of DM and frailty on the incidence of mortality/readmission at 24 months was analysed by a Cox regression model.

RESULTS

A total of 498 patients were included (mean age 84.3 years). Prevalence of previous DM was 199/498 (40.0%). The rate of frail patients was 135/498 (27.1%). The incidence of mortality/readmission was higher frail patients (HR 2.49) (both p<0.001). In contrast, DM was not significantly associated to a higher rate of outcomes (HR 1.23, p=0.060) in the whole cohort. Among non-frail patients, patients with DM had a similar incidence of mortality or readmission (p=0.959). In contrast, among frail patients, DM was significantly associated with a higher incidence of events (HR 1.51, p=0.034).

CONCLUSIONS

Unlike frailty status, DM was not associated to poorer long-term outcome in elderly patients with ACS. Among frail patients the presence of DM seems to provide additional prognostic information.

Influence of Preadmission Frailty on Short- and Mid-Term Prognoses in Octogenarians With ST-Elevation Myocardial Infarction

BACKGROUND

Octogenarians, who are frequently frail, represent a large proportion of patients admitted for ST-segment elevation myocardial infarction (STEMI). We investigated the relationship between frailty, assessed by the Canadian Study of Health and Aging Clinical Frailty Scale (CFS), and short- and mid-term prognoses in octogenarian STEMI patients.

METHODS AND RESULTS

We used a multicenter registry data of 1,301 patients with STEMI undergoing percutaneous coronary intervention (PCI) between January 2014 and December 2016. Of them, 273 were retrospectively analyzed after categorization into 3 groups based on the preadmission CFS (CFS 1-3, 140 patients; CFS 4-5, 99 patients; and CFS 6-8, 34 patients). We evaluated the influence of CFS on overall mortality at 2 years and on non-home discharge, defined as the composite of in-hospital death and new transfer to a hospital or nursing home. During the study period (median, 565 days), the overall mortality and ratio of non-home discharge increased as CFS increased. After adjustment for multivariable analysis, the severely frail continued to be significantly associated with an increased risk of overall mortality (adjusted hazard ratio 2.37; 95% confidence interval [CI] 1.11-5.05; P=0.026) and non-home discharge (adjusted odds ratio 9.50; 95% CI 3.48-25.99; P<0.001).

CONCLUSIONS

Frailty, as assessed by CFS, had an influence on short- and mid-term prognoses in octogenarian patients with STEMI.

Frailty in Older Patients with Acute Coronary Syndrome in Vietnam

Background

There has been limited evidence about frailty in older patients with acute coronary syndrome (ACS) in Vietnam.

Aim

(1) To investigate the prevalence of frailty in older patients hospitalised with ACS and its associated factors; (2) To investigate the impact of frailty on percutaneous coronary intervention (PCI) and adverse outcomes in this population.

Methods

Patients aged ≥60 with ACS admitted to two teaching hospitals in Vietnam were recruited from 9/2017 to 4/2018. Frailty was defined by the Reported Edmonton Frail Scale. Multivariate logistic regression was applied to investigate the associated factors of frailty and the impact of frailty on PCI and adverse outcomes.

Results

There were 324 participants, mean age 73.5±8.3, 39.2% female. The prevalence of frailty was 48.1%. Advanced age, female gender, history of hypertension, heart failure, stroke and chronic kidney disease were significantly associated with a frailty status. Overall, 50.3% of the participants received PCI (58.3% in the non-frail vs 41.7% in the frail, p=0.003). However, frailty did not have an independent impact on PCI (adjusted OR 0.66, 95% CI 0.41–1.08). Frailty was significantly associated with increased risk of having arrhythmia during hospitalisation (adjusted OR 2.24, 95% CI 1.32–3.80), hospital-acquired pneumonia (adjusted OR 2.27, 95% CI 1.24–4.17), in-hospital mortality (adjusted OR 3.02, 95% CI 1.35–6.75), 30-day mortality (adjusted OR 3.28, 95% CI 1.59–6.76), and 30-day readmission (adjusted OR 2.53, 95% CI 1.38–4.63).

Conclusion

In this study, frailty was present in nearly half of older patients with ACS and was associated with increased adverse outcomes. These findings suggest that frailty screening should be performed in older patients with ACS in Vietnam.

Diabetes mellitus, frailty and prognosis in very elderly patients with acute coronary syndromes

BACKGROUND

The magnitude of the association between diabetes (DM) and outcomes in elderly patients with acute coronary syndromes (ACS) is controversial. No study assessed the prognostic impact of DM according to frailty status in these patients.

METHODS

The LONGEVO-SCA registry included unselected ACS patients aged ≥ 80 years. Frailty was assessed by the FRAIL scale. We evaluated the impact of previous known DM on the incidence of death or readmission at 6 months according to status frailty by the Cox regression method.

RESULTS

A total of 532 patients were included. Mean age was 84.3 years, and 212 patients (39.8%) had previous DM diagnosis. Patients with DM had more comorbidities and higher prevalence of frailty (33% vs 21.9%, p = 0.002). The incidence of death or readmission at 6 months was higher in patients with DM (HR 1.52, 95% CI 1.12-2.05, p 0.007), but after adjusting for potential confounders this association was not significant. The association between DM and outcomes was not significant in robust patients, but it was especially significant in patients with frailty [HR 1.72 (1.05-2.81), p = 0.030, p value for interaction = 0.049].

CONCLUSIONS

About 40% of elderly patients with ACS had previous known DM diagnosis. The association between DM and outcomes was different according to frailty status.

Association Between Cardiac Rehabilitation and Frailty

BACKGROUND

Cardiac rehabilitation is a mainstay treatment for patients experiencing an adverse cardiovascular event. Heart disease is important in frailty, but the impact of cardiac rehabilitation on frailty is unclear.

METHODS

Patients were referred to a 12-week group-based exercise and education cardiac rehabilitation program performed twice weekly. Frailty was measured with the use of a 25-item accumulation of deficits frailty index (range 0-1; higher values indicate greater frailty) at cardiac rehabilitation admission and completion. Patients were categorized by the degree of frailty in 0.1 increments.

RESULTS

Of the 4004 patients who enrolled, 2322 (58.0%) completed cardiac rehabilitation with complete data at admission and completion. There were 414 (17.8%), 642 (27.6%), 690 (29.7%), 401 (17.3%), and 175 (7.5%) patients with admission frailty levels of < 0.20, 0.20-0.30, 0.30-0.40, 0.40-0.50, and > 0.50, respectively. Frailty levels improved from cardiac rehabilitation admission (mean 0.34 [95% CI 0.32-0.35]) to completion (0.26 [0.25-0.28]) for those who completed the program (P < 0.001). After adjusting for age, sex, and number of exercise sessions attended, frailty improved in all frailty groups by mean differences of 0.03 (0.02-0.03), 0.05 (0.05-0.06), 0.08 (0.08-0.09), 0.10 (0.09-0.11), and 0.11 (0.10-0.13) in the < 0.20, 0.20-0.30, 0.30-0.40, 0.40-0.50, and > 0.50 frailty groups, respectively. The minimal improvement in frailty scores (≥ 0.03 reduction) was achieved by 48%, 65%, 72%, 76%, and 79% of patients in the the 5 frailty groups, respectively.

CONCLUSIONS

Although higher frailty levels were associated with cardiac rehabilitation drop-out, finishing the program was related to improving frailty levels, especially in patients who were the frailest.

Prognostic value of frailty in elderly patients with acute coronary syndrome: a systematic review and meta-analysis

BACKGROUND

Frailty is common and associated with poorer outcomes in the elderly, but its prognostic value in acute coronary syndromes (ACS) requires clarification. We thus undertook a systematic review and meta-analysis to evaluate the relationship between frailty and poor prognosis in patients with ACS.

METHODS

We systematically searched PubMed, Embase to find literatures which studied the prognostic value of frailty in elderly patients with ACS. Our main endpoints were the all-cause mortality, cardiovascular disease (CVD), major bleeding and readmissions. We pooled studies using random-effect generic inverse variance method, and conducted three pre-specified subgroup analyses.

RESULTS

Of 1216 identified studies, 15 studies were included in our analysis. Compared with the normal group, frailty (HR = 2.65; 95%CI: 1.81-3.89, I2 = 60.2%) and pre-frailty (HR = 1.41; 95%CI: 1.19-1.66, I2 = 0%) were characterized by a higher risk of mortality after adjustment. Frailty also was associated with increased risk of any-type CVD, major bleeding and hospital readmissions in elderly patients with ACS. The pooled effect sizes in frail patients were 1.54 (95%CI: 1.32-1.79), 1.51 (95%CI: 1.14-1.99) and 1.51 (95%CI: 1.09-2.10).

CONCLUSIONS

Frailty provides quantifiable and significant prognostic value for mortality and adverse events in elderly ACS patients, helping doctors to appraise the comprehensive prognosis risk and to applicate appropriate management strategies.

Frailty for predicting all-cause mortality in elderly acute coronary syndrome patients: A meta-analysis

BACKGROUND

Frailty has been identified as a risk factor for mortality in patients with acute coronary syndrome (ACS). This meta-analysis aimed to evaluate the association between frailty and all-cause mortality outcome in patients with ACS.

METHODS

Pubmed and Embase databases were searched up to September 26, 2018 for the observational studies evaluating the association between frailty and all-cause mortality in elderly ACS patients. Outcome measures were in-hospital death, short-term all-cause mortality (≤6 months),and long-term all-cause mortality (≥12 months).The impact of frailty on all-cause mortality was summarized as hazard ratios (HR) with 95% confidence intervals (CI) for the frail versus nonfrail patients.

RESULTS

A total of 9 cohort studies involving 2475 elderly ACS patients were included. Meta-analysis showed that ACS patients with frailty had an increased risk of in-hospital death (HR 5.49; 95% CI 2.19-13.77), short-term all-cause mortality (HR 3.56; 95% CI 1.96-6.48), and long-term all-cause mortality (HR 2.44; 95% CI 1.92-3.12) after adjustment for confounding factors. In addition, prefrailty was also associated with an increased all-cause mortality (HR 1.65; 95% CI 1.01-2.69).

CONCLUSIONS

This meta-analysis demonstrates that frailty independently predicts all-cause mortality in elderly ACS patients. Elderly ACS patients should be assessed the frailty status for improving risk stratification.

Frequency of Renal Dysfunction and Frailty in Patients ≥80 Years of Age With Acute Coronary Syndromes

Although a significant association between renal function and outcomes in patients with acute coronary syndromes (ACS) has been consistently described, little information exists about the magnitude of this association in patients at older ages. No study assessed the prognostic role of renal function according to frailty in patients with ACS. The LONGEVO-SCA registry included unselected ACS patients aged ≥80 years. Frailty was asessesed by the FRAIL scale, and baseline creatinine clearance was calculated by the Cockroff-Gault formula. We evaluated the impact of renal function on mortality or readmission at 6-months according to frailty status by the Cox regression method. A total of 473 patients were assessed, with a mean age of 84.2 years. The distribution of patients across estimated glomerular filtration rate (eGFR) subgroups was as follows: (1) <30 ml/min: n = 76 (16.1%); (2) 30 to 44 ml/min: n = 147 (31.1%); (3) 45 to 60 ml/min: n = 136 (28.8%); and (4) >60 ml/min: n = 114 (24.1%). Patients with lower eGFR values were older, had a higher proportion of comorbidities and other geriatric syndromes (p = 0.001) and underwent less often an invasive management during admission (p < 0.001). The incidence of mortality or readmission at 6 months progressively increased across renal function subgroups (p = 0.001). After adjusting for potential confounders, this association became nonsignificant (p = 0.802). The association between eGFR and outcomes was only significant in patients without frailty (p = 0.001). In conclusion, most patients aged ≥80 years with NSTEACS had renal function impairment at admission. The association between renal function and outcomes was different according to frailty status.

Current situation of frailty screening tools for older adults

Frailty is a geriatric syndrome associated with adverse outcomes such as falls, disability, and mortality. Frailty is common and contributes to rising health care costs. Early screening and timely tailored intervention may effectively prevent or delay the adverse outcomes in older adults. Studies on frailty and its specific measurement tools are increasing in number, but the debate on the screening instruments remains. Currently, self-reported screening tools can identify frailty and predict the risk of adverse outcomes in older adults. Because they are easy to use and quickly provide information, self-reported frailty screening tools have significant implication in primary care settings and clinics. We reviewed the frailty screening instruments in older adults and proposed a two-step pathway for frailty identification, and to manage declines in intrinsic capacity as well as boost resilience.

Recommendations of the Geriatric Cardiology Section of the Spanish Society of Cardiology for the Assessment of Frailty in Elderly Patients With Heart Disease

Frailty is an age-associated clinical syndrome characterized by a decrease in physiological reserve in situations of stress, constituting a state of vulnerability that involves a higher risk of adverse events. Its prevalence in Spain is high, especially in elderly individuals with comorbidity and chronic diseases. In cardiovascular disease, frailty is associated worse clinical outcomes and higher morbidity and mortality in all scenarios, in both acute and chronic settings, and could consequently influence diagnosis and treatment. However, frailty is often not addressed or included when planning the management of elderly patients with heart disease. In this article, we review the available scientific evidence and highlight the most appropriate scales for the measurement and assessment of frailty, some of which are more useful and have better predictive capacity than others, depending on the clinical context. We also underline the importance of properly identifying and assessing frailty in order to include it in the treatment and care plan that best suits each patient.

Invasive strategy and frailty in very elderly patients with acute coronary syndromes

AIMS

Current guidelines recommend an early invasive strategy in patients with non-ST-segment elevation acute coronary syndromes (NSTEACS). The role of an invasive strategy in frail elderly patients remains controversial. The aim of this substudy was to assess the impact of an invasive strategy on outcomes according to the degree of frailty in these patients.

METHODS AND RESULTS

The LONGEVO-SCA registry included unselected NSTEACS patients aged ≥80 years. A geriatric assessment, including frailty, was performed during hospitalisation. During the admission, we evaluated the impact of an invasive strategy on the incidence of cardiac death, reinfarction or new revascularisation at six months. From 531 patients included, 145 (27.3%) were frail. Mean age was 84.3 years. Most patients underwent an invasive strategy (407/531, 76.6%). Patients undergoing an invasive strategy were younger and had a lower proportion of frailty (23.3% vs. 40.3%, p<0.001). The incidence of cardiac events was more common in patients managed conservatively, after adjusting for confounding factors (sub-hazard ratio [sHR] 2.32, 95% confidence interval [CI]: 1.26-4.29, p=0.007). This association remained significant in non-frail patients (sHR 3.85, 95% CI: 2.13-6.95, p=0.001), but was not significant in patients with established frailty criteria (sHR 1.40, 95% CI: 0.72-2.75, p=0.325). The interaction invasive strategy-frailty was significant (p=0.032).

CONCLUSIONS

An invasive strategy was independently associated with better outcomes in very elderly patients with NSTEACS. This association was different according to frailty status.

An Easy Assessment of Frailty at Baseline Independently Predicts Prognosis in Very Elderly Patients With Acute Coronary Syndromes

BACKGROUND

Information about the impact of frailty in patients with acute coronary syndromes (ACS) is scarce. No study has assessed the prognostic impact of frailty as measured by the FRAIL scale in very elderly patients with ACS.

METHODS

The prospective multicenter LONGEVO-SCA registry included unselected patients with ACS aged 80 years or older. A comprehensive geriatric assessment was performed during hospitalization, including frailty assessment by the FRAIL scale. The primary endpoint was mortality at 6 months.

RESULTS

A total of 532 patients were included. Mean age was 84.3 years, 61.7% male. Most patients had positive troponin levels (84%) and high GRACE risk score values (mean 165). A total of 205 patients were classified as prefrail (38.5%) and 145 as frail (27.3%). Frail and prefrail patients had a higher prevalence of comorbidities, lower left ventricle ejection fraction, and higher mean GRACE score value. A total of 63 patients (11.8%) were dead at 6 months. Both prefrailty and frailty were associated with higher 6-month mortality rates (P < .001). After adjusting for potential confounders, this association remained significant (hazard ratio [HR] 2.71; 95% confidence interval [CI] 1.09-6.73 for prefrailty and HR 2.99; 95% CI 1.20-7.44 for frailty, P = .024). The other independent predictors of mortality were age, Charlson Index, and GRACE risk score.

CONCLUSIONS

The FRAIL scale is a simple tool that independently predicts mortality in unselected very elderly patients with ACS. The presence of prefrailty criteria also should be taken into account when performing risk stratification of these patients.