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Revascularization in frail patients with acute coronary syndromes: a retrospective longitudinal study
Marius Roman1, Joanne Miksza1, Florence Yuk-Lin Lai1
1Department of Cardiovascular Sciences and National Institute for Health Research Leicester Biomedical Research Unit in Cardiovascular Medicine, University of Leicester, Groby Road, Leicester LE3 9QP, UK.
Insights
Frailty is common in acute coronary syndrome (ACS) patients. Revascularization improves survival in frail individuals, reducing cardiovascular death risk.
Area of Science:
- Cardiology
- Geriatric Medicine
- Public Health
Background:
- Frailty is increasingly prevalent in patients with acute coronary syndrome (ACS).
- High-risk frail patients are often excluded from clinical trials.
- Uncertainty exists regarding the benefits and risks of invasive management for frail ACS patients.
Purpose of the Study:
- To investigate the association between frailty and outcomes in ACS patients.
- To evaluate the impact of revascularization on cardiovascular mortality in frail ACS patients.
Main Methods:
- Analysis of 565,378 ACS patients in England (2010-2015) using Hospital Episode Statistics and mortality data.
- Frailty defined by the Hospital Frailty Risk Score.
- Causal inference analysis using regional revascularization variation as an instrumental variable.
Main Results:
- 11.6% intermediate and 4.7% high frailty risk identified.
- Higher frailty risk associated with less invasive procedures and increased mortality.
- Revascularization showed greater absolute reduction in cardiovascular mortality for intermediate and high frailty risk patients at 1 year.
Conclusions:
- Frailty is a significant factor in ACS, with cardiovascular disease as the primary cause of death.
- Revascularization offers survival benefits in intermediate and high frailty risk ACS patients.
- Findings support considering revascularization for frail ACS patients.
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.
