Frailty and Outcomes After Myocardial Infarction: Insights From the CONCORDANCE Registry

Abstract

BackgroundLittle is known about the prognostic implications of frailty, a state of susceptibility to stressors and poor recovery to homeostasis in older people, after myocardial infarction (MI).Methods and ResultsWe studied 3944 MI patients aged ≥65 years treated at 41 Australian hospitals from 2009 to 2016 in the CONCORDANCE (Australian Cooperative National Registry of Acute Coronary Care, Guideline Adherence and Clinical Events) registry. Frailty index (FI) was determined using the health deficit accumulation method. All‐cause and cardiac‐specific mortality at 6 months were compared between frail (FI >0.25) and nonfrail (FI ≤0.25) patients. Among 1275 patients with ST‐segment–elevation MI (STEMI), 192 (15%) were frail, and among 2669 non‐STEMI (NSTEMI) patients, 902 (34%) were frail. Compared with nonfrail counterparts, frail STEMI patients received 30% less reperfusion therapy and 22% less revascularization during index hospitalization; frail NSTEMI patients received 30% less diagnostic angiography and 39% less revascularization. Unadjusted 6‐month all‐cause mortality (STEMI: 13% versus 3%; NSTEMI: 13% versus 4%) and cardiac‐specific mortality (STEMI: 6% versus 1.4%, NSTEMI: 3.2% versus 1.2%) were higher among frail patients. After adjustment for known prognosticators, FI was significantly associated with higher 6‐month all‐cause (STEMI: odds ratio: 1.74 per 0.1 FI [95% confidence interval, 1.37–2.22], P<0.001; NSTEMI: odds ratio: 1.62 per 0.1 FI [95% confidence interval, 1.40–1.87], P<0.001) but not cardiac‐specific mortality (STEMI: P=0.99; NSTEMI: P=0.93).ConclusionsFrail patients receive lower rates of invasive cardiac care during MI hospitalization. Increased frailty was independently associated with increased postdischarge all‐cause mortality but not cardiac‐specific mortality. These findings inform identification of frailty during MI hospitalization as a potential opportunity to address competing risks for mortality in this high‐risk population.

The prevalence and importance of frailty in heart failure with reduced ejection fraction – an analysis of PARADIGM‐HF and ATMOSPHERE

“…Moreover, frailty seems to be particularly prevalent in HF compared with other diseases; for example, lower frailty indices, and lower proportion of patients classified as frail, have been reported in chronic kidney disease, chronic obstructive pulmonary disease, and acute coronary syndrome. [23][24][25][26][27][28][29][30][31][32] Only in myeloma patients, with a mean age of 76 years, did we find similar levels of frailty: median FI 0.24, with 52% categorized as frail. 19 Chronic inflammation, sarcopenia and general reduction in physiological reserves are implicated in the pathogenesis of the frailty syndrome.…”

“…19 Chronic inflammation, sarcopenia and general reduction in physiological reserves are implicated in the pathogenesis of the frailty syndrome. [23][24][25][26][27][28][29][30][31][32] Interestingly, we found that increasing frailty was associated with higher levels of inflammation and tissue turnover related biomarkers, especially, growth differentiation factor 15, one of a core panel of frailty biomarkers, thought to reflect mitochondrial dysfunction and cellular senescence, increased with increasing frailty. [33][34][35][36][37][38] Consistent with previous studies, a higher proportion of women in this study were frail (68% vs. 62%), which has been attributed to their lower muscle mass.…”

Hospital readmission and mortality: associations to a hospital frailty risk score in a national sample of US older adults with pre-existing coronary heart disease, an observational study.

“…Similar to the Kundi study our findings showed increased risk of readmission and mortality among frail vs the non-frail in those with CHD (e.g., AMI, HF). Other factors such as the amount and type of treatment received for events of AMI may influence the prevalence of a treatment risk gap that may influence AMI mortality outcomes, and explain some of the difference between all-cause and cardiac related mortality [28].…”

Frailty in Myocardial Infarction Patients: A Paradigm Shift

“…For now, it will suffice to apprehend that a frail status implies a biological age superseding the respective chronological age. 'Insights from the CONCORDANCE Registry' emphasizes that, in patients with significant cardiovascular disease, the prevalence of frailty "may be as high as 60% [7]." Frailty is associated with worst cardiac outcomes after an MI [7].…”

“…'Insights from the CONCORDANCE Registry' emphasizes that, in patients with significant cardiovascular disease, the prevalence of frailty "may be as high as 60% [7]." Frailty is associated with worst cardiac outcomes after an MI [7]. These patients are at an " increased risk of recurrent infarctions and have an annual death rate of 5 per cent" or "six times that in people of the same age who do not have coronary heart disease [5]."…”