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

Updated evidence on selection and implementation of an invasive treatment strategy for older patients with non-ST-segment elevation myocardial infarction

Non-ST-segment elevation myocardial infarction (NSTEMI) is the most common acute coronary syndrome diagnosis in older patients. In the UK, there are ~20 000 NSTEMI cases annually in patients aged ≥75 years. Despite therapeutic advances in pharmacological and invasive management, studies show that older patients with NSTEMI experience worse in-hospital and long-term outcomes than younger patients, suggesting a clear need for robust evidence in this cohort.The European Society of Cardiology guidelines recommend that invasive management should be considered holistically with no specified age cut-offs. However, older patients are less likely to receive invasive management due to a paucity of evidence from trials that represent contemporary clinical characteristics of older adults. Recruiting older patients realistic of those encountered in clinical practice is hugely challenging. Chronological age alone does not reflect the heterogeneity of the older population; ~30% of older patients with NSTEMI are frail, ~65% are cognitively impaired and most live with at least two additional comorbidities that can influence risk. Weighing the risk of an NSTEMI in an older adult against competing risks attributable to underlying frailty, comorbidities and cognitive impairment poses a key challenge.Recently, the SENIOR-RITA trial showed that invasive management in older patients with NSTEMI is safe and reduces non-fatal myocardial infarction and subsequent revascularisation but does not improve mortality. Individualised risk assessment and shared decision-making is necessary to guide these nuanced decisions. This review discusses the latest evidence regarding invasive management in the older population with NSTEMI, including the impact of geriatric syndromes on clinical outcomes.

Revascularization in frail patients with acute coronary syndromes: a retrospective longitudinal study

BACKGROUND AND AIMS

Frailty is increasingly prevalent in people presenting with acute coronary syndrome (ACS). This high-risk group is typically excluded from trials of interventions in ACS, and there is uncertainty about the risks and benefits of invasive management.

METHODS

Patients with an ACS diagnosis between 2010 and 2015 in England were identified from Hospital Episode Statistics, with linked Office for National Statistics mortality data. Frailty was defined by the Hospital Frailty Risk Score. Causal inference analysis used regional variation in revascularization as an instrumental variable to estimate average treatment effects of revascularization on cardiovascular mortality up to 5 years in people presenting with ACS and low-, intermediate-, or high-risk frailty.

RESULTS

The analysis included 565 378 ACS patients, of whom 11.6% (n = 65 522) were at intermediate risk and 4.7% (n = 26 504) were at high risk of frailty. Intermediate and high frailty risks were associated with reduced likelihood of echocardiography, invasive angiography, or revascularization and increased likelihood of mortality and major adverse cardiovascular events compared with low frailty risk. Cardiovascular death at 5 years was 78.6%, 77.3%, and 75.7% in people at low, intermediate, and high frailty risk, respectively. Instrumental variable analysis suggested that revascularization resulted in a higher absolute reduction in cardiovascular mortality in high and intermediate frail risk patients compared with low risk at 1-year post-ACS.

CONCLUSIONS

Frailty is common in people presenting with ACS, where cardiovascular causes are the principal mode of death. Revascularization is associated with short- and long-term survival benefits in people at intermediate and high risk of frailty after adjustment for measured and unmeasured confounders.

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

INTRODUCTION

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

AREAS COVERED

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

EXPERT OPINION

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

Impact of Frailty on Outcome of Older Patients With Non-ST Elevation Acute Myocardial Infarction Who Undergo Percutaneous Coronary Intervention

Frailty status is linked with a poorer clinical outcome, and patients with frailty are often less revascularized, even with percutaneous coronary intervention (PCI). We therefore sought to assess the impact of frailty on the clinical outcome of older patients with non-ST elevation acute myocardial infarction (NSTEMI) who underwent PCI. We prospectively enrolled 141 consecutive older patients (>75 years) admitted for NSTEMI; 104 patients underwent PCI (35 with frailty, 69 without frailty), and 37 were not revascularized (22 with frailty, 15 without). Patients with frailty were older, less frequently male, more affected by dementia and severe left ventricular dysfunction, and less treated with PCI; patients treated with PCI were younger and less affected by dementia. Thirty-day mortality rates were proportionally higher, from 3% in patients without frailty treated with PCI, to 7% in patients without frailty not treated with PCI, 17% in patients with frailty treated with PCI, and 48% in patients with frailty not treated with PCI (p <0.05). Similarly, 6-month mortality rates were proportionally higher (12%, 29%, 37%, and 71%). At multivariable analysis, frail status was associated to a sixfold increased risk of mortality at 30 days; at 6 months, frail status was associated to a 3.4-fold risk of death (p <0.01), but PCI was also associated to a lower risk of mortality (odds ratio 0.2, p <0.01). In an observational study in older patients with NSTEMI, frail status is associated to a poorer outcome, whereas PCI is associated to a better long-term outcome. A careful selection of patient suitable for revascularization by PCI may be useful in improving outcomes of older patients with frailty with NSTEMI.

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

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

Evaluation of the Atherogenic Index of Plasma to Predict All-Cause Mortality in Elderly With Acute Coronary Syndrome: A Long-Term Follow-Up

The Atherogenic Index of Plasma (AIP) is associated with coronary artery disease (CAD) and acute coronary syndrome (ACS), but the relationship between AIP and ACS in elderly patients remains unclear. We investigated the prognostic capability of AIP for in-hospital and long-term mortality in elderly patients with ACS undergoing coronary angiography (CA). We analyzed 627 patients with ACS over 75 years of age who were admitted to our clinic between April 2015 and December 2022 and underwent CA. The primary clinical endpoints were in-hospital, 30-day, 1-year, and long-term mortality. The median follow-up time was 27 months. AIP was defined as log (triglyceride/high-density lipoprotein cholesterol). In-hospital mortality rates for patients with AIP ≤.1 and AIP >.1 were 4.7% and 17.6% (P < .001), 30-day mortality rates were 8.7% and 32.2% (P = .01), 1-year mortality rates were 12.1% and 45.1% (P < .001), and long-term mortality rates were 47.3% and 67.5% (P < .001), respectively. Multivariate Cox regression analysis revealed AIP, age, left ventricle ejection fraction (LVEF), admission creatinine, and Killip ≥2 as independent predictors for long-term mortality. AIP can predict in-hospital and long-time all-cause mortality in elderly patients with ACS undergoing CA. Age, LVEF, admission creatinine, and Killip ≥2 are additional factors that predict long-term all-cause mortality.

Myocardial injury and clinical outcome in octogenarians after non-ST-elevation myocardial infarction

Introduction

The aim of this study was to analyze age-associated myocardial injury and clinical outcome after non-ST-elevation myocardial infarction (NSTEMI).

Methods

This prospective, multicenter study consists of 440 patients with NSTEMI enrolled at 7 centers. All patients were treated with primary percutaneous coronary intervention and underwent cardiac magnetic resonance (CMR) imaging 1-10 days after study inclusion. CMR parameters of myocardial injury and clinical outcome were evaluated by creating 2 subgroups: <80 years vs. ≥80 years. The clinical endpoint was the 1-year incidence of major adverse cardiac events (MACE) consisting of death, re-infarction and new congestive heart failure.

Results

Elderly patients ≥80 years accounted for 13.9% of the study population and showed a divergent cardiovascular risk profile compared to the subgroup of patients <80 years. CMR imaging did not reveal significant differences regarding infarct size, microvascular obstruction, left ventricular ejection fraction or multidimensional strain analysis between the study groups. At 1-year follow-up, MACE rate was significantly increased in patients ≥80 years compared to patients aged <80 years (19.7% vs. 9.6%; p = 0.019). In a multiple stepwise logistic regression model, the number of diseased vessels, aldosterone antagonist use and left ventricular global longitudinal strain were identified as independent predictors for MACE in all patients, while there was no independent predictive value of age regarding 1-year clinical outcome.

Conclusion

This prospective, multicenter analysis shows that structural and functional myocardial damage is similar in younger and older patients with NSTEMI. Furthermore, in this heterogeneous but also clinically representative cohort with reduced sample size, age was not independently associated with 1-year clinical outcome, despite an increased event rate in patients ≥80 years.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

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

BACKGROUND AND AIMS

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

The Impact of Geriatric Conditions in Elderly Patients with Coronary Heart Disease: A State-of-the-Art Review

The growing geriatric population presenting with coronary artery disease poses a primary challenge for healthcare services. This is a highly heterogeneous population, often underrepresented in studies and clinical trials, with distinctive characteristics that render them particularly vulnerable to standard management/approaches. In this review, we aim to summarize the available evidence on the treatment of acute coronary syndrome in the elderly. Additionally, we contextualize frailty, comorbidity, sarcopenia, and cognitive impairment, common in these patients, within the realm of coronary artery disease, proposing strategies for each case that may assist in therapeutic approaches.

Treatment of elderly patients with non-ST-elevation myocardial infarction: the nationwide POPular age registry

OBJECTIVE

We describe the current treatment of elderly patients with non-ST-elevation myocardial infarction (NSTEMI) enrolled in a national registry.

METHODS

The POPular AGE registry is a prospective, multicentre study of patients ≥ 75 years of age presenting with NSTEMI, performed in the Netherlands. Management was at the discretion of the treating physician. Cardiovascular events consisted of cardiovascular death, myocardial infarction and ischaemic stroke. Bleeding was classified according to the Bleeding Academic Research Consortium (BARC) criteria.

RESULTS

A total of 646 patients were enrolled between August 2016 and May 2018. Median age was 81 (IQR 77-84) years and 58% were male. Overall, 75% underwent coronary angiography, 40% percutaneous coronary intervention, and 11% coronary artery bypass grafting, while 49.8% received pharmacological therapy only. At discharge, dual antiplatelet therapy (aspirin and P2Y12 inhibitor) was prescribed to 56.7%, and 27.4% received oral anticoagulation plus at least one antiplatelet agent. At 1‑year follow-up, cardiovascular death, myocardial infarction or stroke had occurred in 13.6% and major bleeding (BARC 3 and 5) in 3.9% of patients. The risk of both cardiovascular events and major bleeding was highest during the 1st month. However, cardiovascular risk was three times as high as bleeding risk in this elderly population, both after 1 month and after 1 year.

CONCLUSIONS

In this national registry of elderly patients with NSTEMI, the majority are treated according to current European Society of Cardiology guidelines. Both the cardiovascular and bleeding risk are highest during the 1st month after NSTEMI. However, the cardiovascular risk was three times as high as the bleeding risk.

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.

Invasive Versus Conservative Management of NSTEMI Patients Aged ≥ 75 Years

BACKGROUND

The efficiency of invasive management in older patients (≥75 years) with non-ST-segment elevation myocardial infarction (NSTEMI) remains ambiguous.

OBJECTIVES

To assess the efficiency of invasive management in older patients with NSTEMI based on meta-analysis and trial sequential analysis (TSA).

METHODS

Relevant randomized controlled trials (RCT) and observational studies were included. The primary outcomes were all-cause death, myocardial infarction, stroke, and major bleeding. Pooled odd ratio (OR) and 95% confidence interval (CI) were calculated. P <0.05 was considered statistically significant.

RESULTS

Five RCTs and 22 observational studies with 1017374 patients were included. Based on RCT and TSA results, invasive management was associated with lower risks of myocardial infarction (OR: 0.51; 95% CI: 0.40-0.65; I2=0%), major adverse cardiovascular events (MACE; OR: 0.61; 95% CI: 0.49-0.77; I2=27.0%), and revascularization (OR: 0.29; 95% CI: 0.15-0.55; I2=5.3%) compared with conservative management. Pooling results from RCTs and observational studies with multivariable adjustment showed consistently lower risks of all-cause death (OR: 0.57; 95% CI: 0.50-0.64; I2=86.4%), myocardial infarction (OR: 0.63; 95% CI: 0.56-0.71; I2=0%), stroke (OR: 0.59; 95% CI: 0.51-0.69; I2=0%), and MACE (OR: 0.64; 95% CI: 0.54-0.76; I2=43.4%). The better prognosis associated with invasive management was also observed in real-world scenarios. However, for patients aged ≥85 years, invasive management may increase the risk of major bleeding (OR: 2.68; 95% CI: 1.12-6.42; I2=0%).

CONCLUSIONS

Invasive management was associated with lower risks of myocardial infarction, MACE, and revascularization in older patients with NSTEMI, yet it may increase the risk of major bleeding in patients aged ≥85 years.

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

Importance

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

Objective

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

Design, Setting, and Participants

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

Interventions

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

Main Outcomes and Measures

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

Results

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

Conclusions and Relevance

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

Trial Registration

ClinicalTrials.gov Identifier: NCT03208153.

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

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

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

Aim

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

Findings

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

Message

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

Purpose

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

Methods

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

Results

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

Conclusions

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

Complete versus culprit-only strategy in older MI patients with multivessel disease

AIMS

The revascularization strategy to pursue in older myocardial infarction (MI) patients with multivessel disease (MVD) is currently unknown. For this reason, while waiting for the results of dedicated trials, we sought to compare a complete versus a culprit-only strategy in older MI patients by merging data from four registries.

METHODS AND RESULTS

The inclusion criteria for the target population of the present study were (i) age ≥ 75 years; (ii) MI (STE or NSTE); (iii) MVD; (iv) successful treatment of culprit lesion. Propensity scores (PS) were derived using logistic regression (backward stepwise selection, p < 0.2). The primary outcome was all-cause mortality. Secondary outcomes were cardiovascular (CV) death, MI, and major bleeding. Multivariable adjustment included the PS and inverse probability of treatment weighting (IPTW). The Kaplan-Meier plots were weighted for IPT. Among 2087 patients included, 1362 (65%) received culprit-only treatment whereas 725 (35%) complete revascularization. The mean age was 81.5 years, while the mean follow-up was 419 ± 284 days. Seventy-four patients (10%) died in the complete group and 223 in the culprit-only one (16%). The adjusted cumulative 1-year mortality was 9.7% in the complete and 12.9% in the culprit-only group (adjusted HR: 0.67, 95% CI: 0.50-0.89). Complete revascularization was associated with lower incidence of CV death (adjusted HR: 0.68, 95% CI: 0.48-0.95) and MI (adjusted HR 0.67, 95% CI: 0.48-0.95).

CONCLUSIONS

Culprit-only is the default strategy in older MI patients with MVD. In our analysis, complete revascularization was associated with lower all-cause and CV mortality and with a lower MI rate.

Interventions for Frailty Among Older Adults With Cardiovascular Disease: JACC State-of-the-Art Review

With the aging of the world's population, a large proportion of patients seen in cardiovascular practice are older adults, but many patients also exhibit signs of physical frailty. Cardiovascular disease and frailty are interdependent and have the same physiological underpinning that predisposes to the progression of both disease processes. Frailty can be defined as a phenomenon of increased vulnerability to stressors due to decreased physiological reserves in older patients and thus leads to poor clinical outcomes after cardiovascular insults. There are various pathophysiologic mechanisms for the development of frailty: cognitive decline, physical inactivity, poor nutrition, and lack of social supports; these risk factors provide opportunity for various types of interventions that aim to prevent, improve, or reverse the development of frailty syndrome in the context of cardiovascular disease. There is no compelling study demonstrating a successful intervention to improve a global measure of frailty. Emerging data from patients admitted with heart failure indicate that interventions associated with positive outcomes on frailty and physical function are multidimensional and include tailored cardiac rehabilitation. Contemporary cardiovascular practice should actively identify patients with physical frailty who could benefit from frailty interventions and aim to deliver these therapies in a patient-centered model to optimize quality of life, particularly after cardiovascular interventions.

Prognosis Impact of Diabetes in Elderly Women and Men with Non-ST Elevation Acute Coronary Syndrome

Few studies have addressed to date the interaction between sex and diabetes mellitus (DM) in the prognosis of elderly patients with non-ST-segment elevation acute coronary syndrome (NSTEACS). Our aim was to address the role of DM in the prognosis of non-selected elderly patients with NSTEACS according to sex. A retrospective analysis from 11 Spanish NSTEACS registries was conducted, including patients aged ≥70 years. The primary end point was one-year all-cause mortality. A total of 7211 patients were included, 2,770 (38.4%) were women, and 39.9% had DM. Compared with the men, the women were older (79.95 ± 5.75 vs. 78.45 ± 5.43 years, p < 0.001) and more often had a history of hypertension (77% vs. 83.1%, p < 0.01). Anemia and chronic kidney disease were both more common in women. On the other hand, they less frequently had a prior history of arteriosclerotic cardiovascular disease or comorbidities such as peripheral artery disease and chronic pulmonary disease. Women showed a worse clinical profile on admission, though an invasive approach and in-hospital revascularization were both more often performed in men (p < 0.001). At a one-year follow-up, 1090 patients (15%) had died, without a difference between sexes. Male sex was an independent predictor of mortality (HR = 1.15, 95% CI 1.01 to 1.32, p = 0.035), and there was a significant interaction between sex and DM (p = 0.002). DM was strongly associated with mortality in women (HR: 1.45, 95% CI = 1.18–1.78; p < 0.001), but not in men (HR: 0.98, 95% CI = 0.84–1.14; p = 0.787). In conclusion, DM is associated with mortality in older women with NSTEACS, but not in men.

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.

Revascularization versus medical therapy in patients aged 80 and older with stable ischemic heart disease

BACKGROUND

Older patients are underrepresented in landmark randomized trials for stable ischemic heart disease (SIHD). Therefore, we sought to evaluate the benefits of revascularization in patients ≥80 years old with SIHD.

METHODS

Retrospective study of patients undergoing invasive coronary angiography (ICA) for SIHD between 2009 and 2019. Patients were grouped according to treatment: revascularization (percutaneous coronary intervention [PCI] or coronary artery bypass grafting [CABG]) versus initial medical therapy alone. Inverse probability of treatment weighting (IPTW)-adjusted Cox proportional hazard regression analyses were performed. Outcomes evaluated were all-cause mortality, non-fatal myocardial infarction (MI), and repeat revascularization.

RESULTS

A total of 1015 patients (median age 83.0, interquartile range [IQR] 81.3-85.2 years; 29% female) underwent ICA for SIHD. Of these, 557 (55%) were treated with revascularization and 458 (45%) with initial medical therapy alone. Baseline characteristics were well balanced after IPTW adjustment. At median follow-up of 3.5 years (IQR 1.7-5.9 years), there were no differences in all-cause mortality and non-fatal MI between treatment groups; but there was an increased need for repeat revascularization (IPTW adjusted hazard ratio 2.22, 95% confidence interval 1.53-3.22) with revascularization. Separately comparing PCI or CABG alone versus medical therapy yielded similar results; as well as in subgroup analysis (except for patients ≥90 years old and those without prior CABG).

CONCLUSION

There were no differences in all-cause mortality and non-fatal MI with invasive revascularization (either PCI or CABG) versus medical therapy alone in patients ≥80 years old with SIHD. Large randomized trials focusing on older patients are warranted to guide clinical practice in this growing population.

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.

Revascularisation or medical therapy in elderly patients with acute anginal syndromes: the RINCAL randomised trial

BACKGROUND

Historically the elderly have been under-represented in non-ST-elevation myocardial infarction (NSTEMI) management trials.

AIMS

The aim of this trial was to demonstrate that an intervention-guided strategy is superior to optimal medical therapy (OMT) alone for treating NSTEMI in elderly individuals.

METHODS

Patients (≥80 years, chest pain, ischaemic ECG, and elevated troponin) were randomised 1:1 to an intervention-guided strategy plus OMT versus OMT alone. The primary endpoint was a composite of all-cause mortality and non-fatal myocardial reinfarction at 1 year. Ethics approval was obtained by the institutional review board of every recruiting centre.

RESULTS

From May 2014 to September 2018, 251 patients (n=125 invasive vs n=126 conservative) were enrolled. Almost 50% of participants were female. The trial was terminated prematurely due to slow recruitment. A Kaplan-Meier estimate of event-free survival revealed no difference in the primary endpoint at 1 year (invasive 18.5% [23/124] vs conservative 22.2% [28/126]; p=0.39). No significant difference persisted after Cox proportional hazards regression analysis (hazard ratio 0.79, 95% confidence interval 0.45-1.35; p=0.39). There was greater freedom from angina at 3 months (p<0.001) after early intervention but this was similar at 1 year. Both non-fatal reinfarction (invasive 9.7% [12/124] vs conservative 14.3% [18/126]; p=0.22) and unplanned revascularisation (invasive 1.6% [2/124] vs conservative 6.4% [8/126]; p=0.10) occurred more frequently in the OMT alone cohort.

CONCLUSIONS

An intervention-guided strategy was not superior to OMT alone to treat very elderly NSTEMI patients. The trial was underpowered to demonstrate this definitively. Early intervention resulted in fewer cases of reinfarction and unplanned revascularisation but did not improve survival.

The effects of percutaneous coronary intervention on mortality in elderly patients with non-ST-segment elevation myocardial infarction undergoing coronary angiography

INTRODUCTION

Although it is recommended that elderly patients with non-ST-segment elevation myocardial infarction (NSTEMI) should undergo an assessment for invasive revascularization, these patients undergo fewer coronary interventions despite the current guidelines. The aim of the study is to evaluate the effectiveness of percutaneous coronary intervention on all-cause mortalities monthly and annually in the population.

METHODS

Three hundred and twenty-four patients with NSTEMI aged 65 years or older who underwent coronary angiography and treated with conservative strategy or percutaneous coronary intervention were included in the study. All demographic and clinical characteristics of the patients were recorded and one-month and one-year follow-up results were analysed.

RESULTS

Two hundred eight cases (64.19%) were treated with percutaneous coronary intervention and 116 cases (35.81%) of the participant were treated with conservative methods. The mean age of the participants was 75.41 ± 6.65 years. The treatment strategy was an independent predictor for the mortality of one-year (HR: 1.965). Furthermore, Killip class ≥2 (HR:2.392), Left Ventricular Ejection Fraction (HR:2.637) and renal failure (HR: 3.471) were independent predictors for one-year mortality.

CONCLUSION

The present study has revealed that percutaneous coronary intervention was effective on one-year mortality in NSTEMI patients over the age of 65. It is considered that percutaneous coronary intervention would decrease mortality in these patients but it should be addressed in larger population studies.

Comorbidity burden and revascularization benefit in elderly patients with acute coronary syndrome

INTRODUCTION AND OBJECTIVES

To evaluate the interaction between comorbidity burden and the benefits of in-hospital revascularization in elderly patients with non-ST-segment elevation acute coronary syndrome (NSTEACS).

METHODS

This retrospective study included 7211 patients aged ≥ 70 years from 11 Spanish NSTEACS registries. Six comorbidities were evaluated: diabetes, peripheral artery disease, cerebrovascular disease, chronic pulmonary disease, renal failure, and anemia. A propensity score was estimated to enable an adjusted comparison of in-hospital revascularization and conservative management. The end point was 1-year all-cause mortality.

RESULTS

In total, 1090 patients (15%) died. The in-hospital revascularization rate was 60%. Revascularization was associated with lower 1-year mortality; the strength of the association was unchanged by the addition of comorbidities to the model (HR, 0.61; 95%CI, 0.53-0.69; P=.0001). However, the effects of revascularization were attenuated in patients with renal failure, peripheral artery disease, and chronic pulmonary disease (P for interaction=.004, .007, and .03, respectively) but were not modified by diabetes, anemia, and previous stroke (P=.74, .51, and .28, respectively). Revascularization benefits gradually decreased as the number of comorbidities increased (from a HR of 0.48 [95%CI, 0.39-0.61] with 0 comorbidities to 0.83 [95%CI, 0.62-1.12] with ≥ 5 comorbidities; omnibus P=.016). The results were similar for the propensity score model. The same findings were obtained when invasive management was considered the exposure variable.

CONCLUSIONS

In-hospital revascularization improves 1-year mortality regardless of comorbidities in elderly patients with NSTEACS. However, the revascularization benefit is progressively reduced with an increased comorbidity burden. Renal failure, peripheral artery disease, and chronic lung disease were the comorbidities with the most detrimental effects on revascularization benefits.

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.

Impact of Different Geriatric Conditions on Choice of Therapy and In-Hospital Outcomes in Elderly Patients with Acute Coronary Syndrome

INTRODUCTION

The clinical benefit of invasive therapy in elderly patients with acute coronary syndrome (ACS) remains unclear. Furthermore, the decision-making process to treat this growing patient group is also debatable. The purpose of this study was to assess the association between elderly ACS patients, the treatment choice and their in-hospital outcomes after non-ST-elevation (NSTE)-ACS in a consecutive series of patients >75 years of age.

METHODS AND RESULTS

Consecutive patients >75 years presenting with NSTE-ACS in our hospital between July 2017 and July 2018 were included during the first 2 days of hospital admission. Demographic data, prior medical history and present medical condition were documented. During day 0 and day 2, geriatric assessments (Clinical Frailty Scale [CFS], Barthel index, Charlson comorbidity index, "timed up and go" test [TUG], Mini-Mental Status Test [MMS], Geriatric Depression Scale [GDS], SF-36 for quality of life, instrumental activities of daily living [IADL], Killip-score, Grace-score and Euro-score) were conducted. After 6 months, patients were re-evaluated. In 106 patients (mean age 81.9±5.3 years, 57% male gender), 68 patients (64%) were treated interventionally, and 38 patients had conservative treatment (36%). Patients treated with intervention were significantly younger (80.9±4.7 years vs 83.5±6.0 years, p=0.015), had a lower rate of prior cerebral events (17.6% vs 26.3%; p=ns) and suffered more often from chronic obstructive pulmonary disease (17.6% vs 34.2%; p=0.050). All other demographic variables were comparable between both groups. The composite clinical endpoint (death, re-infarction, bleeding) was reached in 7 patients (10.3%) of the invasive and in 2 patients (5.3%) of the conservative group. They were not significantly different between both groups. A frailty index, consisting of commonly used parameters of functional impairment in elderly patients, namely, MMS ≤2 at baseline, IADL ≤7, CFS ≥7 and age ≥85 years, significantly predicted conservative treatment.

CONCLUSION

Effective revascularization techniques are still underused in patients of older age in the case of ACS. For decision-making, geriatric tests alone may not predict treatment in those patients, but the combination of different tests may better predict treatment and perhaps the clinical outcomes in those patients. Furthermore, frail patients are at higher risk for not receiving guideline recommended therapy.

Residual SYNTAX Score and One-Year Outcome in Elderly Patients With Acute Coronary Syndrome

Background

The residual burden of coronary artery disease after percutaneous coronary intervention (PCI) has been associated with worse ischemic outcome. However, data are conflicting in elderly patients. The aim of our study was to verify the incremental value of the residual Synergy Between Percutaneous Coronary Intervention With Taxus and Cardiac Surgery (SYNTAX) score (rSS) over clinical variables and baseline SYNTAX score (bSS) in predicting 1-year mortality or cardiovascular events.

Methods

A post hoc analysis of data collected in the Elderly-ACS 2 multicenter randomized trial was performed. We included 630 patients aged > 75 years with multivessel coronary disease undergoing PCI for acute coronary syndrome (ACS). The primary outcome was a composite of death, recurrent myocardial infarction, and stroke at 1-year follow up. Change in c-statistic and standardized net benefit were used to evaluate the incremental value of the rSS.

Results

Event rates were significantly higher in patients with incomplete revascularization (rSS > 8). When the rSS was included in a core Cox regression model containing age, previous myocardial infarction, and ACS type, the hazard ratio for patients with score values > 8 was 2.47 (95% confidence interval, 1.51-4.06). However, the core model with rSS did not increase the c-statistic compared with the core model with the bSS (from 0.69 to 0.70) and gave little incremental value in the standardized net benefit.

Conclusions

In elderly patients with ACS with multivessel disease undergoing PCI, incomplete revascularization was associated with worse outcome at 1-year follow-up. However, there was no clear incremental value of the rSS in the prediction of 1-year adverse outcome compared with a model including clinical variables and bSS.

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.

Toward a geriatric approach to patients with advanced age and cardiovascular diseases: position statement of the EuGMS Special Interest Group on Cardiovascular Medicine

Cardiovascular diseases (CVD) are highly prevalent in older adults and represent a major geriatric health-care concern. Management of CVD in older patients may be challenging due to specific geriatric issues, such as frailty and multi-morbidity, which may influence patients' outcomes. In this clinical context, diagnostic and therapeutic strategies should target those outcomes that have higher priority in geriatric health care, including disability prevention and quality of life. Older adults with CVD should be offered a reasonably optimized treatment, customized to the individual's frailty level and functional status. Yet, most clinical trials excluded comorbid and frail patients and evidence to support CVD management in this vulnerable population is lacking. Therefore, a geriatric approach is needed in cardiovascular medicine, characterized by a holistic, patient-centered perspective focusing on functional status and quality of life. With a view to promote the geriatric approach in the management of older patients with CVD, the EuGMS Special Interest Group (SIG) on Cardiovascular Medicine was founded in 2018, consisting of a network of geriatricians with an extensive expertise in geriatric cardiovascular medicine. The present position paper aims to present the Cardiovascular SIG and illustrate its main purposes and action programs.

Incidence, Clinical Characteristics, and Impact of Acute Coronary Syndrome Following Transcatheter Aortic Valve Replacement

OBJECTIVES

The authors sought to assess the incidence, predictors, management, and prognosis of acute coronary syndrome (ACS) following TAVR.

BACKGROUND

About one-half of the patients undergoing transcatheter aortic valve replacement (TAVR) have concurrent coronary artery disease (CAD). However, the occurrence and clinical impact of coronary events following TAVR remain largely unknown.

METHODS

Consecutive patients undergoing TAVR in our institution between May 2007 and November 2017 were included. Patients were followed at 1, 6, and 12 months, and yearly thereafter. ACS was diagnosed and classified according to the Third Universal Definition of Myocardial Infarction.

RESULTS

A total of 779 patients (mean age 79 ± 9 years, 52% male, mean STS: 6.8 ± 5.1%) were included, 68% of which had a history of CAD. At a median follow-up of 25 (interquartile range: 10 to 44) months, 78 patients (10%) presented at least 1 episode of ACS, with one-half of the events occurring within the year following TAVR. Clinical presentation was type 2 non-ST-segment elevation myocardial infarction (35.9%), unstable angina (34.6%), type 1 non-ST-segment elevation myocardial infarction (28.2%), and ST-segment elevation myocardial infarction (1.3%). Male sex (hazard ratio [HR]: 2.19; 95% confidence interval [CI]: 1.36 to 3.54; p = 0.001), prior CAD (HR: 2.78; 95% CI: 1.50 to 5.18; p = 0.001), and nontransfemoral approach (HR: 1.71; 95% CI: 1.04 to 2.75; p = 0.035) were independently associated with ACS. Coronary angiography was performed in 53 (67.9%) patients with ACS, and 30 of them (56.6%) underwent percutaneous coronary intervention. In-hospital death rate at the time of the ACS episode was 3.8%. At a median follow-up of 21 (interquartile range: 8 to 34) months post-ACS, all-cause and cardiovascular death rates were 37.3% and 25.3%, respectively.

CONCLUSIONS

Approximately one-tenth of patients undergoing TAVR were readmitted for an ACS after a median follow-up of 25 months. Male sex, prior CAD, and nontransfemoral approach were independent predictors of ACS. ACS was associated with high midterm mortality.

Effects of complete revascularization on long-term treatment outcomes in patients with multivessel coronary artery disease over 80 years of age admitted for acute coronary syndrome

Background

The effects of complete revascularization (CR) on long-term treatment outcomes in patients over 80 years of age with acute coronary syndrome (ACS) and multivessel coronary artery disease (MVD) have not been sufficiently investigated.

Methods

In this study, we analyzed data obtained in 305 patients over 80 years of age with MVD who were admitted in the period from January 2014 to August 2017 for ACS. The patients were divided into two groups. CR was performed in 131 patients, and 174 subjects had an intervention on the symptomatic artery only [incomplete revascularization (ICR)]. The primary endpoint was one-year occurrence of the major adverse cardiac events (MACE) including death, non-fatal myocardial infarction, stroke. We also recorded cases of repeat coronary artery intervention, major bleeding events, contrast-induced nephropathy and stent thrombosis that occurred within a period of 1 year.

Results

The MACE rate in patients undergoing CR was significantly lower during the 12-month observation period. No statistically significant differences were observed in the rates of repeat coronary artery intervention, bleeding events, contrast-induced nephropathy, and stent thrombosis.

Conclusions

CR performed in patients over 80 years of age with ACS due to MVD decreases the incidence of MACE without increasing the risk of periprocedural complications.

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.

Mitral Regurgitation and Prognosis After Non-ST-Segment Elevation Myocardial Infarction in Very Old Patients

BACKGROUND/OBJETCTIVES

Mitral regurgitation (MR)after an acute coronary syndrome is associated with a poor prognosis. However,the prognostic impact of MR in elderly patients with non-ST-segment elevation myocardialinfarction (NSTEMI) has not been well addressed.

DESIGN

Prospective registry.

SETTING AND PARTICIPANTS

The multicenter LONGEVO-SCA prospective registry included 532 unselected NSTEMI patients aged ≥80 years.

MEASUREMENTS

MR was quantified using echocardiography during admission in 497 patients. They were classified in two groups: significant (moderate or severe) or not significant MR (absent or mild). We evaluated the impact of MR status on mortality or readmission at 6 months.

RESULTS

Mean age was 84.3±4.1 years, and 308 (61.9%) were males. A total of 108 patients (21.7%) had significant MR. Compared with those without significant MR, they were older and showed worse baseline clinical status, with higher frailty, disability, and risk of malnutrition. They also had lower systolic blood pressure, higher heart rate, worse Killip class, lower left ventricular ejection fraction, and higher pulmonary pressure on admission, as well as more often new onset atrial fibrillation (all p values = 0.001). Patients with significant MR also had higher in-hospital mortality (4.6% vs. 1.3%, p = 0.04), longer hospital stay (median 8 [5-12] vs. 6 [4-10] days, p = 0.002), and higher mortality/readmission at 6 months (hazard ratio 1.54, 95% confidence interval 1.09-2.18, p = 0.015). However, after adjusting for potential confounders, this last association was not significant.

CONCLUSIONS

Significant MR is seen in one fifth of octogenarians with NSTEMI. Patients with significant MR have a poor prognosis, mainly determined by their baseline clinical characteristics. J Am Geriatr Soc 67:1641-1648, 2019.

Comorbidity assessment for mortality risk stratification in elderly patients with acute coronary syndrome

BACKGROUND

The Charlson's is the most used comorbidity index. It comprises 19 comorbidities, some of which are infrequent in elderly patients with acute coronary syndrome (ACS), while some others are manifestations of cardiac disease rather than comorbidities. Our goal was to simplify comorbidity assessment in elderly non-ST-segment elevation ACS patients.

METHODS

The study group consisted of 1 training (n = 920, 76 ± 7 years) and 1 testing (n = 532; 84 ± 4 years) cohorts. The end-point was all-cause mortality at 1-year follow-up. Comorbidities were assessed selecting those medical disorders other than cardiac disease that were independently associated with mortality by multivariable analysis.

RESULTS

A total of 130 (14%) patients died in the training cohort. Six comorbidities were predictive: renal failure, anemia, diabetes, peripheral artery disease, cerebrovascular disease and chronic lung disease. The increase in the number of comorbidities yielded a gradient of risk on top of well-known clinical predictors: ≥3 comorbidities (27% mortality, HR = 1.90, 95% CI 1.20-3.03, p = .006); 2 comorbidities (16% mortality, HR = 1.29, 95% CI 0.81-2.04, p = .30); and 0-1 comorbidities (7.6% mortality, reference category). The discrimination accuracy (C-statistic = 0.80) and calibration (Hosmer-Lemeshow test, p = .20) of the predictive model using the 6 comorbidities was comparable to the predictive model using the Charlson index (C-statistic = 0.80; Hosmer-Lemeshow test, p = .70). Similar results were reproduced in the testing cohort (≥3 comorbidities: 24% mortality, HR = 2.37, 95% CI 1.25-4.49, p = .008; 2 comorbidities: 14% mortality, HR = 1.59, 95% CI 0.82-3.07, p = .20; 0-1 comorbidities: 7.5% reference category).

CONCLUSION

A simplified comorbidity assessment comprising 6 comorbidities provides useful risk stratification in elderly patients with ACS.

Bleeding risk assessment in elderly patients with acute coronary syndrome

Nowadays, elderly people represent a growing population segment with a well known increased risk of both ischemic and bleeding events. Current acute coronary syndrome guidelines, strongly recommend dual antiplatelet therapy (DAPT) with few specific references for aged patients due to lack of evidence. Patients aged ≥ 75 years are misrepresented in the classic derivation trials cohorts. Strategies to reduce the bleeding risk in this group of patients are urgently needed for the daily clinical practice. Identify the specific age related bleeding risk factors and the importance of an integral geriatric assessment remains challenging. Some of the available in-hospital and out-hospital bleeding risk scores have shown a lower to moderate predictive ability in older patients and no specific tools are developed in elderly population. The importance of an appropriate vascular access choice, type and duration of antiplatelet drugs is crucial to reduce the bleeding risk. Increase radial approaches and short DAPT duration leads to reduce hemorrhages. One interesting subgroup of patients is those who need chronic anticoagulation therapy after percutaneous coronary intervention, due to their very high risk of bleeding. New alternatives as dual therapy with oral anticoagulation and only one antiplatlet drug should be considered. In current review, we evaluate the available evidence about bleeding risk in elderly.