Frailty Burden and Efficacy of Initial Invasive Strategy in Chronic Coronary Disease: The ISCHEMIA Trials
Lajjaben Patel1, Matthew W Segar2, Muhammad S Usman1
1Division of Cardiology, Department of Medicine, UT Southwestern Medical Center, Dallas, Texas, USA.
Insights
Frailty in chronic coronary disease patients doesn't alter invasive treatment benefits for clinical events. However, frailer patients experience greater quality of life improvements with invasive strategies.
Area of Science:
- Cardiology
- Geriatrics
- Clinical Outcomes Research
Background:
- Frailty is prevalent in patients with chronic coronary disease (CCD).
- Frailty is linked to poorer clinical outcomes in CCD patients.
- Understanding frailty's impact on treatment efficacy is crucial.
Purpose of the Study:
- To investigate if baseline frailty modifies treatment effects in CCD patients.
- To assess the impact of frailty on clinical outcomes and health-related quality of life (HRQoL).
Main Methods:
- Pooled analysis of ISCHEMIA and ISCHEMIA-CKD trials.
- Frailty assessed using Frailty Index (FI) and categorized into tertiles.
- Cox models evaluated treatment interaction with frailty on composite outcomes and HRQoL (Seattle Angina Questionnaire [SAQ]).
Main Results:
- Higher frailty burden correlated with lower baseline SAQ scores and increased adverse events.
- Frailty did not significantly modify the invasive strategy's effect on the primary composite outcome.
- Frailty significantly modified HRQoL outcomes, with greater SAQ score improvements at 1 year for frailer patients receiving invasive treatment.
Conclusions:
- Higher frailty burden in CCD patients may lead to greater HRQoL gains with invasive management, without increased clinical risk.
- Lower baseline SAQ scores predict enhanced HRQoL improvement with invasive treatment, irrespective of frailty.
- Initial invasive strategy shows potential for improved HRQoL in frail CCD patients.
Background:
Frailty is common among patients with chronic coronary disease and is associated with worse outcomes.
Methods:
A pooled, post hoc analysis of the ISCHEMIA and ISCHEMIA-CKD trials was conducted. Baseline frailty was assessed using a Frailty Index (FI), and participants were categorized into data-derived tertiles. Multivariable Cox models with multiplicative interaction terms (frailty × treatment arm) were constructed to evaluate whether baseline frailty status modified the treatment effect of the initial invasive (vs conservative) strategy on a composite outcome of cardiovascular death, myocardial infarction, hospitalization for unstable angina, heart failure, or resuscitated cardiac arrest and the secondary outcome of HRQoL (Seattle Angina Questionnaire [SAQ]).
Results:
Among 5322 participants (mean 64 years, 24% female), a high frailty burden (tertile 3 vs. tertile 1) was associated with lower baseline SAQ scores and increased risk of adverse clinical outcomes on follow-up. Baseline frailty burden did not significantly modify the effect of the initial invasive strategy on the primary composite outcome (P interactionfrailty × intervention arm = 0.30). However, frailty significantly modified the effect of the initial invasive strategy on HRQoL, with higher baseline frailty burden associated with greater improvement in SAQ scores at 1 year with initial invasive (vs. conservative) treatment (P interactionfrailty × intervention arm < 0.001). The treatment effect of an initial invasive vs. conservative strategy on 12-month SAQ score change was most pronounced in individuals with lower baseline SAQ scores in both higher and lower frailty burden groups.
Conclusion:
Patients with chronic coronary disease with a higher frailty burden are more likely to experience greater improvements in HRQoL with initial invasive management without a higher risk of adverse clinical events. Lower baseline SAQ scores predicted greater improvement in HRQoL with initial invasive management, independent of frailty burden.
