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

BACKGROUND

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

METHODS

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

RESULTS

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

5877Comorbidity 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.

Purpose

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=0.006); 2 comorbidities (16% mortality, HR=1.29, 95% CI 0.81–2.04, p=0.30); and 0–1 comorbidities (7.6% mortality, reference category). The discrimination accuracy (C-statistic= 0.80) and calibration (Hosmer-Lemeshow test, p=0.20) 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=0.70). Similar results were reproduced in the testing cohort (≥3 comorbidities: 24% mortality, HR=2.37, 95% CI 1.25–4.49, p=0.008; 2 comorbidities: 14% mortality, HR=1.59, 95% CI 0.82–3.07, p=0.20; 0–1 comorbidities: 7.5% reference category).

Kaplan-Meyer curves for mortality

Conclusion

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

Acknowledgement/Funding

This work was supported by grants from Spain's Ministry of Economy and Competitiveness through the Carlos III Health Institute

Growth differentiation factor 15 and geriatric conditions in acute coronary syndrome

BACKGROUND

Growth differentiation factor 15 (GDF-15) is a marker of cell senescence. Age is a well-known determinant of GDF-15 levels, yet no study has analyzed the relationship between geriatric conditions and GDF-15. We hypothesize that geriatric conditions reflecting biological age might be stronger determinants of GDF-15 than chronological age in elderly patients with acute coronary syndrome.

METHODS

A total of 208 patients (mean age = 78.3 ± 7.0 years) were included. Prior to discharge, a thorough geriatric assessment was performed and GDF-15 measured. Predictors of GDF-15 (transformed by its natural logarithm) were determined with linear regression. Furthermore, Cox regression was used for the analysis of all-cause mortality. The median follow-up was 728 days.

RESULTS

Median GDF-15 concentration was 2432 pg/ml. In multivariate analysis, frailty (Fried score, p = 0.001), and comorbidity (Charlson index, p = 0.003) were independent determinants of lnGDF-15 while age was not significant (p = 0.17). Other covariates included in the model were male gender (p = 0.017), diabetes (p = 0.169), Killip class ≥2 (p = 0.046) and glomerular filtration rate (p = 0.001). The Fried score and Charlson index provided significant incremental value in the R² model (0.362 vs 0.447; p = 0.0001). A total of 66 (32%) patients died. LnGDF-15 was a significant mortality predictor (HR = 1.82, 95% CI 1.12-2.94, p = 0.015) along with the Fried score (p = 0.013) and the Charlson index (p = 0.030).

CONCLUSIONS

Geriatric conditions are strong determinants of GDF-15 levels on top of age in acute coronary syndromes. Furthermore, GDF-15 was associated with mortality independently of geriatric status. Geriatric assessment and GDF-15 are complementary tools.