Is frailty associated with short-term outcomes for elderly patients with acute coronary syndrome?

Background Frailty is a new prognostic factor in cardiovascular medicine due to the aging and increasingly complex nature of elderly patients. It is useful and meaningful to prospectively analyze the manner in which frailty predicts short-term outcomes for elderly patients with acute coronary syndrome (ACS). Methods Patients aged ? 65 years, with diagnosis of ACS from cardiology department and geriatrics department were included from single-center. Clinical data including geriatrics syndromes were collected using Comprehensive Geriatrics Assessment. Frailty was defined according to the Clinical Frailty Scale and the impact of the co-morbidities on risk was quantified by the coronary artery disease (CAD)—specific index. Patients were followed up by clinical visit or telephone consultation and the median follow-up time is 120 days. Following-up items included all-cause mortality, unscheduled return visit, in-hospital and recurrent major adverse cardiovascular events. Multivariable regression survival analysis was performed using Cox regression. Results Of the 352 patients, 152 (43.18%) were considered frail according to the study instrument (5?7 on the scale), and 93 (26.42%) were considered moderately or severely frail (6?7 on the scale). Geriatrics syndromes including incontinence, fall history, visual impairment, hearing impairment, constipation, chronic pain, sleeping disorder, dental problems, anxiety or depression, and delirium were more frequently in frail patients than in non-frail patients (P = 0.000, 0.031, 0.009, 0.014, 0.000, 0.003, 0.022, 0.000, 0.074, and 0.432, respectively). Adjusted for sex, age, severity of coronary artery diseases (left main coronary artery lesion or not) and co-morbidities (CAD specific index) by Cox survival analysis, frailty was found to be strongly and independently associated with risk for the primary composite outcomes: all-cause mortality [Hazard Ratio (HR) = 5.393; 95% CI: 1.477?19.692, P = 0.011] and unscheduled return visit (HR = 2.832; 95% CI: 1.140?7.037, P = 0.025). Conclusions Comprehensive Geriatrics Assessment and Clinical Frail Scale were useful in evaluation of elderly patients with ACS. Frailty was strongly and independently associated with short-term outcomes for elderly patients with ACS.     

Age,treatment, and outcomes in high-risk non‐ST-segment elevation acute coronary syndrome patients: Insights from the EARLY ACS trial

Background

Elderly patients with acute coronary syndromes (ACS) are at high risk for death and recurrent thrombotic events. We evaluated the efficacy and safety of intensive treatment with glycoprotein IIb/IIIa inhibitors in an elderly population, and the relationships between age, timing of administration, and clinical outcomes.

Methods

We used data from high-risk non–ST-segment elevation ACS patients randomized to early eptifibatide vs. delayed provisional use at percutaneous coronary intervention. In multivariable models, we included age × treatment interaction terms to assess whether treatment effect varied by age after adjusting for confounders.

Results

Of 9406 patients, 13.9% were aged < 55 years; 27.6%, 55–64 years; 33.2%, 65–74 years; and 25.3%, ≥ 75 years. For each 10-year age increase, the adjusted odds ratio (OR) (95% confidence interval [CI]) for 96-hour death, myocardial infarction (MI), recurrent ischemia requiring urgent revascularization, or thrombotic bailout was 1.13 (1.04–1.23) and for 30-day death or MI was 1.13 (1.04–1.22). Increasing age was also associated with greater 1-year mortality (adjusted hazard ratio per 10 years: 1.44, 95% CI 1.30–1.60). There was no interaction between age and treatment (p interaction = 0.99, 0.54, and 0.87, respectively). Increasing age was associated with more non‐coronary artery bypass grafting-related TIMI major bleeding (adjusted OR and 95% CI per 10 years: 1.54 [1.24–1.92]), GUSTO moderate/severe bleeding (1.52 [1.33–1.75]), and transfusion (1.25 [1.07–1.45]). The amount by which TIMI major bleeding was increased with early vs. delayed provisional eptifibatide use was significantly greater with increasing age (p interaction = 0.02), but the age × treatment interactions were not significant for GUSTO moderate/severe bleeding or transfusion (p interaction = 0.33 and 0.54, respectively).

Conclusion

Increasing age was associated with greater risk for ischemic events and more bleeding. Despite higher baseline ischemic risk in older patients, there was no preferential benefit of early vs. delayed provisional eptifibatide use for ischemic outcomes as age increased, but the incremental bleeding risk was amplified.     

Low-molecular-weight heparin compared with unfractionated heparin for patients with non–ST-segment elevation acute coronary syndromes treated with glycoprotein IIb/IIIa inhibitors: Results from the CRUSADE initiative

Background: Both heparin and glycoprotein (GP) IIb/IIIa inhibitor therapy and early invasive management strategies are recommended by the American College of Cardiology (ACC)/American Heart Association (AHA) guidelines for the treatment of patients with non–ST-segment elevation acute coronary syndromes (NSTE ACS). However, controversy exists about which form of heparin—unfractionated (UF) or low-molecular-weight (LMW)—is preferable. We sought to compare the efficacy and safety of these treatment strategies in a large contemporary population of patients with NSTE ACS. Methods: Using data from the CRUSADE Initiative, we evaluated LMWH and UFH in high-risk NSTE ACS patients (positive cardiac markers and/or ischemic ST-segment changes) who had received early (< 24 hours) GP IIb/IIIa inhibitor therapy and underwent early invasive management. In-hospital outcomes were compared among treatment groups. Results: From a total of 11,358 patients treated at 407 hospitals in the US from January 2002–June 2003, 6881 (60.6%) received UFH and 4477 (39.4%) received LMWH. Patients treated with UFH were more often admitted to a cardiology inpatient service (73.6% vs. 65.5%, P < 0.0001) and more frequently underwent diagnostic catheterization (91.8% vs. 85.9%, P < 0.0001) and percutaneous coronary intervention (PCI) (69.7% vs. 56.9%, P < 0.0001) than patients treated with LMWH. The point estimate of the adjusted risk of in-hospital death or reinfarction was slightly lower among patients treated with LMWH (odds ratio [OR] 0.81, 95% confidence interval [CI] 0.67–0.99) and the risk of red blood cell transfusion was similar (OR 1.01, 95% CI 0.89–1.15). Among patients who underwent PCI within 48 hours, adjusted rates of death (OR 1.14, 95% CI 0.71–1.85), death or reinfarction (OR 0.93, 0.67–1.31), and transfusion (OR 1.16, 0.89–1.50) were similar. Patients who underwent PCI more than 48 hours into hospitalization had reduced rates of death (OR 0.64, 0.46–0.88), death or reinfarction (OR 0.57, 0.44–0.73), and transfusion (OR 0.66, 0.52–0.84). Conclusions: In routine clinical practice, patients treated with GP IIb/IIIa inhibitors have slightly improved outcomes and similar bleeding risks with LMWH than with UFH. These findings are consistent with current ACC/AHA guidelines but raise important questions about the safety and effectiveness of antithrombotic therapy in real-world clinical practice. Abbreviations abstract Using data from the CRUSADE Initiative, we evaluated low-molecular-weight heparin (LMWH) and unfractionated heparin (UFH) in high-risk patients with non–ST-segment elevation acute coronary syndromes (NSTE ACS) who received early (<24 hours) glycoprotein (GP) IIb/IIIa inhibitors and early invasive management. In-hospital outcomes were compared among treatment groups. LMWH was associated with slightly improved clinical outcomes and similar rates of transfusion compared with UFH. Our results support the current ACC/AHA guidelines recommendations but raise concerns about the safety and efficacy of UFH in the setting of background use of upstream GP IIb/IIIa inhibitors for patients with NSTE ACS in routine clinical practice. CRUSADE is funded by Millennium Pharmaceuticals, Inc. (Cambridge, Massachusetts) and Schering Corporation (Kenilworth, New Jersey). Bristol-Myers Squibb/Sanofi Pharmaceuticals Partnership provides an unrestricted grant in support of the program.