Comorbidity assessment for mortality risk stratification in elderly patients with acute coronary syndrome
Juan Sanchis1, Meritxell Soler1, Julio Núñez1
1Servei de Cardiologia, Hospital Clínic Universitari de València, INCLIVA, Universitat de València, CIBERCV, València, Spain.
Insights
A simplified 6-comorbidity assessment accurately predicts mortality in elderly acute coronary syndrome (ACS) patients. This approach offers a more focused and effective tool for risk stratification compared to the Charlson index.
Area of Science:
- Geriatric Medicine
- Cardiology
- Epidemiology
Background:
- The Charlson Comorbidity Index, widely used for risk stratification, includes 19 conditions, some of which are uncommon or are cardiac manifestations in elderly acute coronary syndrome (ACS) patients.
- Existing comorbidity indices may not be optimally tailored for the specific demographic of elderly individuals experiencing ACS.
- A need exists for a simplified and more relevant comorbidity assessment tool for this patient population.
Purpose of the Study:
- To develop and validate a simplified comorbidity assessment for elderly patients with non-ST-segment elevation ACS.
- To identify key comorbidities independently associated with 1-year all-cause mortality in this specific patient group.
- To compare the predictive performance of the simplified index against the established Charlson index.
Main Methods:
- Two cohorts (training: n=920; testing: n=532) of elderly patients with non-ST-segment elevation ACS were analyzed.
- Multivariable analysis identified comorbidities (excluding cardiac disease) independently associated with 1-year all-cause mortality.
- A predictive model was constructed using the identified significant comorbidities and its accuracy (C-statistic) and calibration were assessed.
Main Results:
- Six comorbidities—renal failure, anemia, diabetes, peripheral artery disease, cerebrovascular disease, and chronic lung disease—were independently predictive of mortality.
- The presence of ≥3 of these comorbidities was associated with a significantly higher risk of 1-year mortality (HR=1.90 in training, HR=2.37 in testing).
- The simplified 6-comorbidity model demonstrated comparable discrimination (C-statistic=0.80) and calibration to the Charlson index in both cohorts.
Conclusions:
- A simplified comorbidity assessment focusing on six key conditions provides effective risk stratification for elderly ACS patients.
- This streamlined approach offers a practical alternative to more complex indices like the Charlson index for this demographic.
- The findings support the utility of this simplified model in clinical practice for identifying high-risk elderly ACS patients.
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.
Related Concept Videos
01:30Acute Coronary Syndrome I: Introduction
01:26Acute Coronary Syndrome V: Nursing Management
01:30Acute Coronary Syndrome III: Diagnostic Studies
01:28Acute Coronary Syndrome IV: Interprofessional Care
01:19Acute Coronary Syndrome II: Pathophysiology and Clinical Manifestations
01:26Nephrotic Syndrome II : Assessment and Medical Management