Frailty, comorbidity, cardiovascular disease burden and quality of life in older patients with non ST elevation acute coronary syndrome managed by invasive strateg

M. D. ThesisBackground: Acute coronary syndrome among older patients is associated with increased morbidity and mortality. In developed countries, there is an increase in the number of older patients managed by invasive strategy. Frailty is emerging as an independent marker of adverse cardiovascular outcomes and its prevalence among older patients undergoing invasive treatment in the setting of Non ST Elevation Acute Coronary Syndrome (NSTEACS) is not known. The impact of frailty, co-morbidity and cardiovascular status on cardiovascular outcomes and quality of life in older patients with NSTEACS managed by invasive strategy is not known. Aims: 1. To determine the prevalence of frailty and compare frailty status by Fried and Rockwood Frailty scales 2. To assess adverse cardiovascular outcomes at one month according to frailty status in older NSTEACS patients managed by invasive strategy 3. To assess cardiovascular disease burden in relation to frailty status 4. To assess comorbidity burden according to frailty status and asses its relation to adverse CV outcomes at one month 5. To evaluate cardiac symptom burden and the quality of life in older NSTEACS patients managed by invasive strategy 6. Assess cognitive function in older NSTEACS patients and its association with frailty Methods: This prospective observational study was conducted in Freeman Hospital, Newcastle upon Tyne. The study participants underwent invasive management of NSTEACS as per the guidelines. Fried Frailty Classification (FFC) was used to group patients as frail (F), pre-frail (PF) and robust (R); and Rockwood Frailty Classification (RFC) grouped patients as frail (F) and non-frail (NF). Charlson co-morbidity index was calculated to quantify co-morbidity burden. To assess the cognitive status of patients during admission, the Montreal Cognitive Assessment was utilised. Arterial stiffness, peripheral arterial tonometry, carotid intima media thickness (CIMT) and left ventricular function were evaluated for cardiovascular status assessment. Quality of life was assessed using Short Form 36 and EuroQoL questionnaires. All these assessments ii were done prior to invasive management. Procedural complications, in-hospital complications and cardiovascular outcomes at 30 days were recorded. Results: Frailty was three times more common by FFC (30.8%) tool compared to RFC (10.1%). There was no significant difference by frailty status in adverse CV outcomes, in-hospital (9.6% vs. 4.2% vs. 2.2%, p=0.157 for F vs. PF vs. R by FFC and 4.2% vs. 5.6%, p=1.0 for F vs. NF by RFC) and at 30-days (11.0% vs. 5.9% vs. 4.3%, p=0.302 and 8.3% vs. 7.0%, p=0.685 respectively). Measures of arterial stiffness, endothelial dysfunction and CIMT did not vary between the patient groups. LV systolic function was similar in frail patients, but increased E/e’ was noted in frail patients suggestive of diastolic dysfunction. Frail patients had worsening dyspnoea severity by both frailty classifications but angina was worse in frail patients by RFC alone. Higher comorbidity burden was noted in frail patients by both FFC (43.8% vs. 24.6% vs. 13.0%, p=0.001 respectively) and RFC (54.2% vs 25.4%, p=0.007) but did not have an association with rate of adverse CV outcomes. Subclinical cognitive impairment was more common in frail patients by Fried (67.2 % vs. 39.6% vs. 42.2%, p=0.002) and Rockwood (86.4% vs. 31.8%, P<0.001) classification. Physical components of QoL measures by EQ5D and SF-36 were lower in frail patients by both frailty classification but mental component by SF-36 was lower in frail patients by RFC only. Conclusion: Frailty was common among older patients with NSTAECS managed by invasive treatment strategy and the prevalence of frailty varied according to the assessment tool used. Frailty was not associated with short-term adverse CV outcomes, but long-term outcomes need to be studied. Higher comorbidity burden, subclinical cognitive impairment and poor QoL measures were more prevalent in frail patients. Vascular status measures like arterial stiffness, endothelial dysfunction and CIMT were not associated with frailty. Dedicated frailty assessment tool for older patients with coronary artery disease need to be developed. Frail patients may stand to benefit more from contemporary management strategy in the short term and frailty should not preclude them from being offered invasive treatment for coronary artery disease

Frailty Scores and Their Utility in Older Patients with Cardiovascular Disease

The world’s population is ageing, resulting in more people with frailty receiving treatment for cardiovascular disease (CVD). The emergence of novel interventions, such as transcatheter aortic valve implantation, has also increased the proportion of older patients being treated in later stages of life. This increasing population burden makes the assessment of frailty of utmost importance, especially in patients with CVD. Despite a growing body of evidence on the association between frailty and CVD, there is no consensus on the optimal frailty assessment tool for use in clinical settings. Previous studies have shown limited concordance between validated frailty instruments. This review evaluates the evidence on the utility of frailty assessment tools in patients with CVD, and the effect of frailty on different outcomes measured

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

Is the contemporary care of the older persons with acute coronary syndrome evidence-based?

Globally, ischaemic heart disease is the leading cause of death, with a higher mortality burden amongst older adults. Although advancing age is associated with a higher risk of adverse outcomes following acute coronary syndrome (ACS), older patients are less likely to receive evidence-based medications and coronary angiography. Guideline recommendations for managing ACS are often based on studies that exclude older patients, and more contemporary trials have been underpowered and produced inconsistent findings. There is also limited evidence for how frailty and comorbidity should influence management decisions. This review focuses on the current evidence base for the medical and percutaneous management of ACS in older patients and highlights the distinct need to enrol older patients with ACS into well-powered, large-scale randomized trials