Frailty assessment and risk prediction by GRACE score in older patients with acute myocardial infarction

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.

Frailty in acute coronary syndromes. A systematic review and narrative synthesis of frailty assessment tools and interventions from randomised controlled trials

AIM

We aimed to review all randomised controlled trial (RCT) data to explore optimal identification and treatment strategies of frail patients with Acute Coronary Syndromes (ACS).

METHODS

The protocol was preregistered (PROSPERO - CRD42021250235). We performed a systematic review including RCT's that 1; used at least one frailty assessment tool to assess frailty and its impact on outcomes in patients diagnosed with ACS and 2; used at least one intervention where change in frailty was measured in patients diagnosed with ACS. The Cochrane Central Register of Controlled Trials, MEDLINE and EMBASE were searched on the 1st April 2021 and updated on 4th July 2023. Owing to low search output results are presented as a narrative synthesis of available evidence.

RESULTS

A single RCT used a frailty assessment tool. A single RCT specifically targeted frailty with their intervention. This precluded further quantitative analysis. There was indication of selection bias against frail participants, and a signal of value for physical activity measurement in frail ACS patients. There was a high level of uncertainty and low level of robustness of this evidence.

CONCLUSIONS

Data from RCT's alone is inadequate in answering the reviews question. Future RCT's need to address ways to incorporate frail participants, whilst mitigating selection biases. Physical performance aspects of the frailty syndrome appear to be high yield modifiable targets that improve outcomes. Intervention trials should consider using change in frailty status as an outcome measure. Any trials that include frail participants should present data specifically attributable to this group.

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

Background

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

Methods

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

Results

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

Conclusion

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

Prevalence and Impact of Frailty in Patients ≥70 Years Old with Acute Coronary Syndrome Referred for Coronary Angiography

INTRODUCTION

Elderly patients with acute coronary syndrome (ACS) have a higher risk of adverse cardiovascular events and may be frail but are underrepresented in clinical trials. Previous studies have proposed that frailty assessment is a better tool than chronological age, in assessing older patients' biological age, and may exceed conventional risk scores in predicting the prognosis. Therefore, we wanted to investigate the prevalence and impact on 12-month outcomes of frailty in patients ≥70 years with ACS referred for coronary angiography (CAG).

METHODS

Patients ≥70 years with ACS referred for CAG underwent frailty scoring with the clinical frailty scale (CFS). Patients were divided into three groups depending on their CFS: robust (1-3), vulnerable (4), and frail (5-9) and followed for 12 months.

RESULTS

Of 455 patients, 69 (15%) patients were frail, 79 (17%) were vulnerable, and 307 (68%) were robust. Frail patients were older (frail: 80.9 ± 5.7 years, vulnerable: 78.5 ± 5.5 years, and robust: 76.6 ± 4.9 years, p < 0.001) and less often treated with percutaneous coronary intervention (frail: 56.5%, vulnerable: 53.2%, and robust: 68.6%, p = 0.014). 12-month mortality was higher among frail patients (frail: 24.6%, vulnerable: 21.8%, and robust: 6.2%, p < 0.001). Frailty was associated with a higher mortality after adjustment for age, sex, comorbidities, the Global Registry of Acute Coronary Events (GRACE) score, and revascularisation (HR 2.67, 95% CI 1.30-5.50, p = 0.008). There was no difference between GRACE and CFS in predicting 12-month mortality (p = 0.893).

CONCLUSIONS

Fifteen percent of patients ≥70 years old with ACS referred for CAG are frail. Frail patients have significantly higher 12-month mortality. GRACE and CFS are similar in predicting 12-month mortality.

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

AIMS

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

DATA SOURCES

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

STUDY SELECTION

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

RESULTS

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

CONCLUSION

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

Association of preoperative clinical frailty and clinical outcomes in elderly patients with stable coronary artery disease after percutaneous coronary intervention

There are few reports on the long-term clinical outcome after percutaneous coronary intervention (PCI) in patients with stable coronary artery disease (CAD) complicated with frailty. This novel study investigated the association between pre-PCI frailty and long-term clinical outcomes in elderly patients aged 65 years or older with stable CAD who underwent elective PCI. We assessed 239 consecutive patients aged 65 years or older with stable CAD who underwent successful elective PCI at Kagoshima City Hospital between January 1st, 2017 and December 31st, 2020. Frailty was retrospectively assessed using the Canadian Study and Aging Clinical Frailty Scale (CFS). Based on the pre-PCI CFS, patients were divided into two groups: the non-frail (CFS < 5) and the frail (CFS ≥ 5) group. We investigated the association between pre-PCI CFS and major adverse cardiovascular events (MACEs) defined as the composite of all-cause death, non-fatal myocardial infarction, non-fatal stroke, and heart failure requiring hospitalization. Additionally, we assessed the association between pre-PCI CFS and major bleeding events defined as Bleeding Academic Research Consortium (BARC) type 3 or 5 bleeding. The mean age was 74.8 ± 7.0 years, and 73.6% were men. According to the pre-PCI frailty assessment, 38 (15.9%) and 201 (84.1%) were classified as frail and non-frail groups, respectively. During a median follow-up of 962 (607-1284) days, 46 patients developed MACEs and 10 patients developed major bleeding events. Kaplan-Meier curves showed a significantly higher incidence of MACE in the frail group compared to those in the non-frail group (Log-rank p < 0.001). Even in multivariate analysis, pre-PCI frailty (CFS ≥ 5) was independently associated with MACE (HR 4.27, 95% CI 1.86-9.80, p-value: < 0.001). Additionally, the cumulative incidence of major bleeding events was significantly higher in the frail group than in the non-frail group (Log-rank p = 0.001). Pre-PCI frailty was an independent risk factor for MACE and bleeding events in elderly patients with stable CAD who underwent elective PCI.

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

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

A Systematic Review: Do the Use of Machine Learning, Deep Learning, and Artificial Intelligence Improve Patient Outcomes in Acute Myocardial Ischemia Compared to Clinician-Only Approaches?

Cardiovascular diseases (CVDs) present a significant global health challenge and remain a primary cause of death. Early detection and intervention are crucial for improved outcomes in acute coronary syndrome (ACS), particularly acute myocardial infarction (AMI) cases. Artificial intelligence (AI) can detect heart disease early by analyzing patient information and electrocardiogram (ECG) data, providing invaluable insights into this critical health issue. However, the imbalanced nature of ECG and patient data presents challenges for traditional machine learning (ML) algorithms in performing unbiasedly. Investigators have proposed various data-level and algorithm-level solutions to overcome these challenges. In this study, we used a systematic literature review (SLR) approach to give an overview of the current literature and to highlight the difficulties of utilizing ML, deep learning (DL), and AI algorithms in predicting, diagnosing, and prognosis of heart diseases. We reviewed 181 articles from reputable journals published between 2013 and June 15, 2023, focusing on eight selected papers for in-depth analysis. The analysis considered factors such as heart disease type, algorithms used, applications, and proposed solutions and compared the benefits of algorithms combined with clinicians versus clinicians alone. This systematic review revealed that the current ML-based diagnostic approaches face several open problems and issues when implementing ML, DL, and AI in real-life settings. Although these algorithms show higher sensitivities, specificities, and accuracies in detecting heart disease, we must address the ethical concerns while implementing these models into clinical practice. The transparency of how these algorithms operate remains a challenge. Nevertheless, further exploration and research in ML, DL, and AI are necessary to overcome these challenges and fully harness their potential to improve health outcomes for patients with AMI.

Assessment and Management of Older Adults Undergoing PCI, Part 1: A JACC: Advances Expert Panel

As the population ages, older adults represent an increasing proportion of patients referred to the cardiac catheterization laboratory. Older adults are the highest-risk group for morbidity and mortality, particularly after complex, high-risk percutaneous coronary interventions. Structured risk assessment plays a key role in differentiating patients who are likely to derive net benefit vs those who have disproportionate risks for harm. Conventional risk assessment tools from national cardiovascular societies typically rely on 3 pillars: 1) cardiovascular risk; 2) physiologic and hemodynamic risk; and 3) anatomic and procedural risks. We propose adding a fourth pillar: geriatric syndromes, as geriatric domains can supersede all other aspects of risk.

Combined nutritional and frailty screening improves assessment of short-term prognosis in older adults following percutaneous coronary intervention

BACKGROUND

Frailty and malnutrition are well-known factors influencing outcomes of myocardial infarction (MI) in older adults. Due to considerable overlap between both entities, whether the simultaneous assessment of frailty and nutrition adds nonredundant value to risk assessment is unknown.

METHODS

We performed a prospective cohort study on 402 patients aged at least 65 years diagnosed with ST-elevation MI that underwent percutaneous coronary intervention. Nutritional status was assessed by Controlling Nutritional Status score (CONUT), Prognostic Nutritional Index, and Geriatric Nutritional Response Index. Frailty was assessed by Clinical Frailty Scale (CFS), Derby frailty index, and acute frailty network. Primary outcome was major adverse cardiac events (MACE), comprising all-cause mortality, non-fatal MI, and unplanned repeat revascularization during 28-day follow-up. Increment in Global Registry of Acute Coronary Events (GRACE) score performance following the addition of nutrition and frailty was assessed.

RESULTS

The incidence of MACE was 8.02 (6.38-9.95) per 1000 person-days. The CONUT score and CFS were the best predictors of MACE and independent predictors in the multivariate Cox-regression models [hazard ratios, 2.80 (1.54-5.09) and 2.54 (1.50-4.29)]. CONUT score classified 151 (37.6%) patients as malnourished, and CFS classified 131 (32.6%) as frail. The addition of both CONUT and CFS to the GRACE score led to better model discrimination and calibration through improved c-statistic (+0.165) ( P < 0.0001) and Akaike and Bayesian information criteria.

CONCLUSION

Combining CONUT and CFS provides nonredundant prognostic value despite their overlapping nature. Combined nutritional and frailty screening may improve risk prognostication in older adults following MI.

Relationship Between Frailty, Sociodemographic and Clinical Characteristics, and Disease Severity of Older Adults With Acute Coronary Syndrome

This study aimed to evaluate the relationship between frailty, sociodemographic and clinical characteristics, and disease severity of older adults with acute coronary syndrome (ACS). A total of 57 hospitalized patients ≥60 years with ACS were assessed for frailty through the Tilburg Frailty Indicator. Disease severity was assessed by the Global Registry of Acute Coronary Events, by the maximum troponin level, and by the number of severely obstructed coronary arteries. The relationship between variables was assessed by Mann Whitney's test, Pearson's chi-square test, likelihood-ratio test, Fisher's exact test, or Student's t test. Analyses were bootstrapped to 1,000 to reduce potential sample bias. About 54.4% were frail. Frailty was associated with ethnicity (p = .02), marital status (p = .05), ischemic equivalents (p = .01), self-perceived health (p = .002), arthritis/rheumatism/arthrosis (p = .002), and number of severely obstructed coronary arteries (p = .05). These relationships can support intensified surveillance planning for the elderly at greatest risk, structuring of transitional care, appropriate nurse-coordinated secondary prevention delivery in primary care, and cardiac rehabilitation following ACS.

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

Background

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

Purpose

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

Design

Systematic review with narrative synthesis.

Methods

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

Results

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

Conclusion

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

Combination of the Barthel Index at Discharge with GRACE Leads to Improved One-Year Mortality Prediction in Older Patients with Acute Myocardial Infarction

Purpose

Many older patients with acute myocardial infarction (AMI) have impaired ability for activities of daily living (ADL). Impaired ADL leads to poor prognosis in elderly patients. The Global Registry of Acute Coronary Events (GRACE) score is widely used for risk stratification in AMI patients but does not consider physical performance, which is an important prognosis predictor for older adults. This study assessed whether the Barthel Index (BI) score combine the GRACE score would achieve improved one-year mortality prediction in older AMI patients.

Patients and Methods

This single-center retrospective study included 688 AMI patients aged ≥65 years who were divided into an impaired ADL group (BI ≤60, n = 102) and a normal ADL group (BI >60, n = 586) based on BI scores at discharge. The participants were followed up for one year. Cox survival models were constructed for BI score, GRACE score, and BI score combined GRACE score for one-year mortality prediction.

Results

Patients had a mean age of 76.29 ± 7.42 years, and 399 were men (58%). A lower BI score was associated with more years of hypertension and diabetes, less revascularization, longer hospital stays, and higher one-year mortality after discharge. Multivariable Cox regression analysis identified BI as a significant risk factor for one-year mortality in older AMI patients (HR 0.977, 95% CI, 0.963-0.992, P = 0.002). BI (0.774, 95% CI: 0.731-0.818) and GRACE (0.758, 95% CI: 0.704-0.812) scores had similar predictive power, but their combination outperformed either score alone (0.810, 95% CI: 0.770-0.851).

Conclusion

BI at discharge is a significant risk factor for one-year mortality in older AMI patients, which can be better predicted by the combination of BI and GRACE scores.

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.

Prevalence and adverse outcomes of frailty in older patients with acute myocardial infarction after percutaneous coronary interventions: A systematic review and meta-analysis

BACKGROUND

The association between frailty and older patients with acute myocardial infarction (AMI) after percutaneous coronary intervention (PCI) is unclear. Therefore, we conducted a systematic review and meta-analysis to investigate the prevalence of frailty in older patients with AMI following PCI, and determine the relationship between frailty and adverse outcomes in these patients.

HYPOTHESIS

Older patients with AMI have a higher prevalence of frailty after PCI, and the frailty in these patients increases the risk of adverse outcomes.

METHODS

A comprehensive search of the PubMed, Cochrane, Ovid (Medline), Ovid (Embase), and Web of Science databases was performed for articles published until October 2021. A meta-analysis was performed using stata12.0 software. A random-effects model was used when I² was greater than 50%; otherwise, a fixed-effects model was used.

RESULTS

There were a total of 274,976 older patients in the included studies. Nine studies investigated the prevalence of frailty in older patients with AMI after PCI, with an overall prevalence of 39% (95% confidence interval [CI]: 18%-60%, p < .001). Six studies included adverse outcomes of frailty in older patients with AMI after PCI, including all-cause mortality (hazard ratio [HR] = 2.29, 95% CI: 1.65-3.16, p = .285), rehospitalization (HR = 2.53, 95% CI: 1.38-4.63), and in-hospital major bleeding (HR = 1.93, 95% CI: 1.29-2.90, p = .825).

CONCLUSION

The frailty prevalence is increased in older patients with AMI after PCI, especially in ST-segment elevation myocardial infarction (STEMI). AMI with frailty after PCI is more likely to be associated with worse clinical outcomes, such as death, bleeding, and rehospitalization.

Performance of the APOP-screener for predicting in-hospital mortality in older COVID-19 patients: a retrospective study

BACKGROUND

A variety of prediction models concerning COVID-19 have been proposed since onset of the pandemic, but to this date no gold standard exists. Mortality rates show a sharp increase with advancing age but with the large heterogeneity of this population in terms of comorbidities, vulnerability and disabilities, identifying risk factors is difficult. Therefore, we aimed to research the multidimensional concept of frailty, measured by the Acute Presenting Older Patient (APOP)-screener, as a risk factor for in-hospital mortality in older COVID-19 patients.

METHODS

All consecutive patients of 70 years or older, with a PCR confirmed COVID-19 infection and a completed APOP-score, presenting at the Emergency Department (ED) of the Jeroen Bosch Hospital, the Netherlands, between February 27th 2020 and February 1st 2021 were retrospectively included. We gathered baseline characteristics and scored the CCI and CFS from patient records. The primary outcome was in-hospital mortality.

RESULTS

A total of 292 patients met the inclusion criteria. Approximately half of the patients were considered frail by the APOP or CFS. 127 patients (43.5%) scored frail on the CFS, 158 (54.1%) scored high risk on the APOP-screener. 79 patients (27.1%) died during their hospital admission. The APOP-screener showed a significantly elevated risk of in-hospital mortality when patients scored both high risk of functional and evidence of cognitive impairment (OR 2.24, 95% 1.18-4.25). Significant elevation of in-hospital mortality was found for the high CCI-scores (≥ 5)(OR 1.78, 95% 1.02-3.11), but not for the highest CFS category (5-9, frail) (OR 1.35, 95% 0.75-2.47). The discriminatory performance of the APOP, CFS and CCI were comparable (AUC resp. 0.59 (0.52-0.66), 0.54 (0.46-0.62) and 0.58 (0.51-0.65)).

CONCLUSION

Although the elevated risk for in-hospital mortality found for the most frail patients as scored by the APOP, this instrument has poor discriminatory value. Additionally, the CFS did not show significance in predicting in-hospital mortality and had a poor discriminatory value as well. Therefore, treatment decisions based on frailty or comorbidities alone should be made with caution. Approaching the heterogeneity of the older population by adding frailty as assessed by the APOP-score to existing prediction models may enhance the predictive value of these models.

Frailty as a Predictor of In-Hospital Outcome in Patients with Myocardial Infarction

(1) Background: Frailty is a condition associated with aging, co-morbidity, and disability. We aimed to investigate the relationship between frailty and in-hospital outcome in patients with myocardial infarction (MI), including the occurrence of delirium, hospital-acquired pneumonia (HAP), and length of hospital stay. (2) Methods: We analyzed 55 patients ≥ 75 years old with ST-elevation and non-ST-elevation MI. Assessment with Abbreviated Mental Test Score (AMTS), Activity of Daily Living (ADL), Instrumental Activity of Daily Living (IADL) and Clinical Frailty Scale (CFS) was performed. (3) Results: In ROC analysis, IADL and CFS presented good predictive values for the occurrence of delirium (AUC = 0.81, p = 0.023, and AUC = 0.86, p = 0.009, respectively). For predicting HAP, only AMTS showed a significant value (AUC = 0.69, p = 0.036). In regression analyses, all tests presented significant predictive values for delirium. For predicting HAP, only IADL and CFS presented significant values (in an analysis adjusted for age, gender and type of MI). Frail patients (≥5 points in CFS) had longer hospital stays (10 days IQR: 8–17 vs. 8 days IQR: 7–10; p = 0.03). (4) Conclusions: While recognizing the limitations of our study associated with the relatively low sample size, we believe that our analysis shows that frailty is a predictor of poorer in-hospital outcomes in patients with MI, including higher rates of delirium, HAP and longer hospital stay.

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

External validation of the GRACE risk score and the risk-treatment paradox in patients with acute coronary syndrome

Objectives

To validate the Global Registry of Acute Coronary Events (GRACE) risk score and examine the extent and impact of the risk–treatment paradox in contemporary patients with acute coronary syndrome (ACS).

Methods

Data from 5015 patients with ACS enrolled in the FORCE-ACS registry between January 2015 and December 2019 were used for model validation. The performance of the GRACE risk score for predicting in-hospital and 1-year mortality was evaluated based on indices of model discrimination and calibration. Differences in the delivery of guideline-recommended care among patients who survived hospitalisation (n=4911) per GRACE risk stratum were assessed and the association with postdischarge mortality was examined.

Results

Discriminative power of the GRACE risk score was good for predicting in-hospital (c-statistic: 0.86; 95% CI: 0.83 to 0.90) and 1-year mortality (c-statistic: 0.82; 95% CI: 0.79 to 0.84). However, the GRACE risk score overestimated the absolute in-hospital and 1-year mortality risk (Hosmer-Lemeshow goodness-of-fit test p<0.01). Intermediate-risk and high-risk patients were 12% and 29% less likely to receive optimal guideline-recommended care compared with low-risk patients, respectively. Optimal guideline-recommended care was associated with lower mortality in intermediate- and high-risk patients.

Conclusions

The GRACE risk score identified patients at higher risk for in-hospital and 1-year mortality, but overestimated absolute risk levels in contemporary patients. Optimal guideline-recommended care was associated with lower mortality in intermediate-risk and high-risk patients, but was less likely to be delivered with increasing mortality risk.

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.

Association between frailty and C-terminal agrin fragment with 3-month mortality following ST-elevation myocardial infarction

The objective of this study was to evaluate the association between frailty, evaluated by the Clinical Frailty Scale (CFS) and FRAIL scale, and C-terminal agrin fragment (CAF) levels with 3-month mortality following ST-segment elevation myocardial infarction (STEMI). This was a prospective observational study that included patients over the age of 18 years with STEMI admitted to the coronary intensive care unit. Within 48 h of admission, the CFS and FRAIL scale were applied and blood samples collected for serum CAF evaluation. Patients were followed for 3 months after hospital discharge, and mortality was recorded. One hundred and eleven patients were included; mean age was 62.3 ± 12.4 years, 61.3% were male and 11.7% died during the 3 months of follow-up. According to the CFS, 79.3% of the patients were classified as not frail, 12.6% as pre-frail and 8.1% as frail. According to the FRAIL scale, 31.5% of the patients were classified as not frail, 53.2% as pre-frail and 15.3% as frail. In univariate analysis, the CFS but not FRAIL scale was associated with mortality. In multiple logistic regression analysis, pre-frail/frail according to CFS (odds ratio [OR]: 6.118; CI 95%: 1.344-27.848; p = 0.019) and CAF levels (OR: 0.943; CI 95%: 0.896-0.992; p = 0.024) were associated with increased 3-month mortality. In a sub-analysis of 53 patients ≥65 years, CFS and CAF levels were associated with 3-month mortality. In conclusion, CAF levels and frailty determined by the CFS were associated with 3-month mortality after STEMI in the general and older population.

Incorporating Frailty Into the Pooled Cohort Equations to Predict Cardiovascular Disease Among Persons With HIV

BACKGROUND

The 2013 Pooled Cohort Equations (PCEs) have underestimated cardiovascular disease (CVD) events among persons with HIV (PWH). We evaluate whether the addition of frailty improves PCE's ability to estimate CVD risk among aging PWH.

SETTING

Multicenter study.

METHODS

We assessed baseline frailty and 5-year atherosclerotic CVD risk using PCEs for participants in the AIDS Clinical Trials Group A5322 observational study. The primary outcome was incident CVD. We fit Cox proportional hazards regression models for incident CVD with (1) PCEs alone and (2) PCEs and frailty together (which included separate models for frailty score, frailty status, slow gait speed, and weak grip strength). We evaluated discrimination ability for the models with and without frailty by comparing their areas under receiver operating characteristic curve (AUCs) and Uno C-statistics, as well as by calculating the net reclassification improvement and integrated discrimination improvement.

RESULTS

The analysis included 944 A5322 participants (759 men, 185 women, median age 50 years, 47% White non-Hispanic). Thirty-nine participants experienced incident CVD during the study period. PCEs predicted 5-year CVD risk in all models. With frailty score, frailty status, slow gait speed, or weak grip strength added, the AUC and C-statistics were relatively unchanged, and the NRI and integrated discrimination improvement indicated little improvement in model discrimination. However, frailty score independently predicted CVD risk [frailty score: hazard ratio = 1.30, 95% confidence interval (CI) = 1.00 to 1.70, P = 0.05].

CONCLUSIONS

Frailty did not improve the predictive ability of PCEs. Baseline PCEs and frailty score independently predicted CVD. Incorporation of frailty assessment into clinical practice may provide corroborative and independent CVD risk estimation.

Modern NCDR and ACTION risk models outperform the GRACE model for prediction of in-hospital mortality in acute coronary syndrome in a German cohort

BACKGROUND AND PURPOSE

Risk prediction with the Global Registry of Acute Coronary Events (GRACE) risk model is guideline-recommended in acute coronary syndrome (ACS) patients. However, the performance of more contemporary scores derived from ACTION (Acute Coronary Treatment and Intervention Outcomes Network) and National Cardiovascular Data (NCDR) registries remains incompletely understood. We aimed to compare these models in German ACS patients.

METHODS AND RESULTS

A total of 1567 patients with (Non-)ST-segment elevation myocardial infarction (NSTEMI: 1002 patients, STEMI: 565 patients) undergoing invasive management at University Hospital Düsseldorf (Germany) from 2014 to 2018 were included. Overall in-hospital mortality was 7.5% (NSTEMI 3.7%, STEMI 14.5%). Parameters for calculation of GRACE 1.0, GRACE 2.0, ACTION and NCDR risk models and in-hospital mortality were assessed and risk model performance was compared. The GRACE 1.0 risk model for prediction of in-hospital mortality discriminated risk superior (c-index 0.84) to its successor GRACE 2.0 (c-index 0.79, p_{GRACE1.0vsGRACE2.0} = 0.0008). The NCDR model performed best in discrimination of risk in ACS overall (c-index 0.89; p_ACTIONvsNCDR < 0.0001; p_GRACEvsNCDR < 0.0001) and showed superior performance compared to GRACE in NSTEMI and STEMI subgroups (p_GRACEvsNCDR both < 0.02). ACTION and GRACE risk models performed comparable to each other (both c-index 0.84, p_{GRACEvsACTION} = 0.68), with advantages for ACTION in NSTEMI patients (c-index 0.87 vs. 0.84 (GRACE); p_{GRACEvsACTION} = 0.02). ACTION and GRACE 2.0 showed the most accurate calibration of all models.

CONCLUSIONS

In a contemporary German patient population with ACS, modern NCDR and ACTION risk models showed superior performance in prediction of in-hospital mortality compared to the gold-standard GRACE model.

Barthel Index as a Predictor of Mortality in Patients with Acute Coronary Syndrome: Better Activities of Daily Living, Better Prognosis

Background

The Barthel index (BI) is a widely used assessment tool for evaluating physical performance in activities of daily living (ADL). The association between BI scores and mortality in hospital and during follow-up of acute coronary syndrome (ACS) patients remains unclear. The present study investigated whether the BI score could be used as a predictor for mortality of ACS.

Methods

We investigated ACS patients from the multi-center Retrospective Evaluation of Acute Chest Pain (REACP) study. The association between BI scores and all-cause mortality of patients with ACS was analyzed by Cox proportional hazards models. The primary endpoint was all-cause death and the secondary endpoint was cardiac death during follow-up.

Results

Among 2908 patients with ACS enrolled, 277 (9.5%) patients died within a median follow-up time of 10.6 months. Patients with lower BI had higher risks of mortality, compared with those with higher BI in ACS patients. Kaplan–Meier analysis revealed that patients with lower BI had worse survival rates than patients with higher BI (P < 0.001). After adjustment for potential influencing factors, multivariate Cox regression analysis showed that the BI was independently associated with all-cause mortality and cardiac mortality, respectively.

Conclusion

The BI at admission has the powerful potential to provide useful prognostic information of early risk stratification, and routine recording of the BI at the ED visit may help in decision-making and health care planning for patients with ACS.