More vulnerable, but still treatable: Frail heart patients benefit from PCI, CABG
Revascularization is less common when intermediate- and high-risk frail patients experience a heart attack or unstable angina. Instead, they are often treated with medications alone. However, a new analysis in European Heart Journal confirmed that these patients do experience significant benefits from revascularization that can last for many years.[1]
Frailty is associated with high rates of cardiovascular disease (CVD) events, but frail patients who present with acute coronary syndromes (ACS) are often excluded from clinical trials. Hoping to learn more about the safety and effectiveness of revascularization among this vulnerable population, researchers tracked data from more than 550,000 ACS patients who underwent treatment from 2010 to 2015. All patients presented due to an ST-elevation myocardial infarction (STEMI), non-ST elevation myocardial infarction (NSTEMI) or unstable angina. While 83.7% of patients faced a low risk of frailty, 11.6% faced an intermediate risk and another 4.7% faced a high risk. As one may expect, the high-risk frailty patients were older and more likely to present with various comorbidities. Also, NSTEMI diagnoses were more common among this group than STEMI or unstable angina.
All patients who underwent revascularization were treated with either percutaneous coronary intervention (PCI) or coronary artery bypass grafting (CABG). Other patients were treated with medical therapy alone.
Tracking the likelihood of investigations and interventions
ACS patients facing a high risk of frailty were less much likely to undergo medical investigations or treatments than intermediate- and low-risk patients. For instance, they were associated with lower rates of both angiography (11.9% vs. 27% vs. 65.8%) and echocardiography (29.6% vs. 35.8% vs. 44.4%). The same was also true for PCI (5.9% vs. 13.4% vs. 40.3%) and CABG (0.4% vs. 1.8% vs. 6.3%).
The study’s authors performed several separate adjusted analyses and confirmed that high-risk frailty patients were 83% less likely to undergo angiography, 38% less likely to undergo echocardiography, 75% less likely go undergo PCI and 91% less likely to undergo CABG.
Instead of interventions and/or treatment, these high-risk patients were typically treated with medical management alone.
Frail cardiac patient outcomes after treatment
In-hospital mortality rates were 25.1% for high-risk frailty patients, 19.9% for intermediate-risk patients and 8.5% for low-risk frailty patients. The high-risk patients were also linked to longer hospital stays.
One-year all-cause mortality, meanwhile, was 55.2% for high-risk frailty patients, 43.2% for intermediate-risk patients and 17% for low-risk frailty patients. The same trend continued when exploring all-cause mortality after five years, with the rates increasing to 88.2% for high-risk frailty patients, 74.2% for intermediate-risk patients and 33% for low-risk frailty patients. Cardiovascular death was consistently the No. 1 cause of death for all risk groups over time.
Perhaps the team’s most noteworthy finding, however, was the fact that revascularization was associated with a bigger absolute reduction in one-year mortality for intermediate- and high-risk frailty patients than it was for low-risk frailty patients. Intermediate- and high-risk patients also experienced significant survival benefits after five years, confirming that PCI and CABG can still have a substantial impact on the health of these more vulnerable patients.
“Frailty is common in people presenting with ACS, where cardiovascular causes are the principal mode of death,” wrote Marius Roman, MD, a clinical lecturer in cardiac surgery with the University of Leicester, and colleagues. “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. Further research is required to validate these findings within the broader context of complex healthcare needs and priorities for this vulnerable and increasing patient group.”
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Michael has more than 18 years of experience as a professional writer and editor. He has written at length about cardiology, radiology, artificial intelligence and other key healthcare topics.