In a report in this issue of the JACC: Cardiovascular Interventions, Dr. John A Dodson and his colleagues from the New York University School of Medicine reported that frail patients had lower use of cardiac catheterization and higher risk of major bleeding (when catheterization was performed) as compared to non-frail patients, thereby drawing attention to clinical strategies to avoid bleeding imperative in this population.
Frailty is a syndrome characterized by slowness, weakness, weight loss, and impaired homeostasis that occurs across multiple body systems (constitutional, neuromuscular, and vascular) and predicts how patients respond to surgical or medical stresses. Although many definitions of frailty had been proposed, all included vulnerability as a fundamental component. Since it was already known that older adults with acute myocardial infarction (AMI) were at increased risk for in-hospital bleeding compared with younger patients, Dodson et al. aimed to evaluate whether frailty was associated with increased bleeding risk in the setting of acute myocardial infarction (AMI). In order to determine this, frailty was examined among AMI patients 65 years of age treated at 775 U.S. hospitals participating in the ACTION (Acute Coronary Treatment and Intervention Outcomes Network) Registry from January 2015 to December 2016. Frailty was classified on the basis of impairments in 3 domains: walking (unassisted, assisted, wheelchair/nonambulatory), cognition (normal, mildly impaired, moderately/severely impaired), and activities of daily living. Impairment in each domain was scored as 0, 1, or 2, and a summary variable consisting of 3 categories was then created:0 (fit/well), 1 to 2 (vulnerable/mild frailty), and 3 to 6 (moderate-to-severe frailty). Multivariable logistic regression was used to examine the independent association between frailty and bleeding.
“This is an important analysis as it helps to transform the rote recording of frailty from a mere quality metric in the medical record into an actionable diagnosis. For example, if a frail patient with AMI is at low moderate risk for poor outcomes, he or she may decide against an invasive procedure if the incremental risk from associated frailty and other age-associated determinants outweighs the benefits of an invasive procedure. Alternatively, a frail person at high risk may be a better candidate for invasive procedures if he or she can undergo a transradial approach. In this way, diagnosing frailty in a patient with AMI facilitates clinical decision-making and helps to personalize an approach to optimize outcomes.”- Dr. John A. Bittl, M.D.
Using data for 129,330 AMI patients, the investigators found that 16.4% of patients at least 65 years of age with AMI had at least some degree of frailty. Moreover, frail patients were older, more often female, and were less likely to undergo cardiac catheterization. Major bleeding increased across categories of frailty (fit/well 6.5%; vulnerable/mild frailty 9.4%; moderate-to-severe frailty 9.9%; p < 0.001). Among patients who underwent catheterization, both frailty categories were independently associated with bleeding risk compared with the non-frail group (vulnerable/mild frailty adjusted odds ratio [OR]: 1.33, 95% confidence interval [CI]: 1.23 to 1.44; moderate-to-severe frailty adjusted OR: 1.40, 95% CI: 1.24 to 1.58). Additionally, the data showed that among patients managed conservatively, there was no association of frailty with bleeding (vulnerable/mild frailty adjusted OR: 1.01, 95% CI: 0.86 to 1.19; moderate-to-severe frailty adjusted OR: 0.96, 95% CI: 0.81 to 1.14).
Therefore, the investigators concluded that frailty (based on a composite score of impairments in walking, cognition, or activities of daily living) was an independent risk factor for bleeding after adjusting for known predictors in the ACTION Registry bleeding model. However, they believe that future exploration in the form of a formal evaluation of frailty in older adults with AMI may assist with informed decision making about the risks and benefits of invasive therapies. In an accompanying editorial titled ‘Invasive Cardiac Procedures Increase Bleeding in Frail Patients With Acute Myocardial Infarction: A Call to Action,” Dr. John A. Bittl, Interventional Cardiology Group, Florida Hospital Ocala wrote, “Dodson et al. are commended for performing an important analysis. Although prior studies have identified an association between frailty and mortality in patients with acute coronary syndrome, the present study helps to transform the rote recording of frailty from a mere quality metric in the medical record into an actionable diagnosis. For example, if a frail patient with AMI is at low moderate risk for poor outcomes, he or she may decide against an invasive procedure if the incremental risk from associated frailty and other age-associated determinants outweighs the benefits of an invasive procedure. Alternatively, a frail person at high risk may be a better candidate for invasive procedures if he or she can undergo a transradial approach. In this way, diagnosing frailty in a patient with AMI facilitates clinical decision-making and helps to personalize an approach to optimize outcomes.” Indeed, the observations made by Dodson et al. are important, because they identify the importance of diagnosing frailty in patients with AMI and the significance of using strategies to reduce bleeding.
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