Frailty in Acute and Chronic Coronary Syndrome Patients Entering Cardiac Rehabilitation

Abstract

Worldwide population ageing is partly due to advanced standard of care, leading to increased incidence and prevalence of geriatric syndromes such as frailty and disability. Hence, the age at the onset of acute coronary syndromes (ACS) keeps growing as well. Moreover, ageing is a risk factor for both frailty and cardiovascular disease (CVD). Frailty and CVD in the elderly share pathophysiological mechanisms and associated conditions, such as malnutrition, sarcopenia, anemia, polypharmacy and both increased bleeding/thrombotic risk, leading to a negative impact on outcomes. In geriatric populations ACS is associated with an increased frailty degree that has a negative effect on re-hospitalization and mortality outcomes. Frail elderly patients are increasingly referred to cardiac rehabilitation (CR) programs after ACS; however, plans of care must be tailored on individual’s clinical complexity in terms of functional capacity, nutritional status and comorbidities, cognitive status, socio-economic support. Completing rehabilitative intervention with a reduced frailty degree, disability prevention, improvement in functional state and quality of life and reduction of re-hospitalization are the goals of CR program. Tools for detecting frailty and guidelines for management of frail elderly patients post-ACS are still debated. This review focused on the need of an early identification of frail patients in elderly with ACS and at elaborating personalized plans of care and secondary prevention in CR setting.

Frailty Syndrome in Older Adults with Cardiovascular Diseases–What Do We Know and What Requires Further Research?

“…Because of the increased risk of bleeding in frail patients undergoing PCI after ACS, a short DAPT is suggested. The PRECISE-DAPT (PREdicting Bleeding Complications In patients undergoing Stent Implantation and subsEquent Dual Anti Platelet Therapy) scale for stratifying bleeding risk at one year after PCI should be routinely evaluated as it serves to adjust DAPT recommendations [ 2 ]. Advanced age and FS are two common conditions for which the benefit-risk ratio of extending DAPT beyond 12 months must be carefully weighed in light of risk for ischemic events and hemorrhagic events.…”

“…Determining the best and optimal methods to identify frailty to develop individualized models of care [ 2 ], as well as develop interventions to reduce or reverse frailty status [ 20 , 54 ];…”

“…It has been shown that CVD also triples the likelihood of Frailty syndrome (FS) [ 1 ]. Thus, as the older adult population grows, FS will be a significant social and medical problem [ 2 ]. Frailty syndrome is a geriatric syndrome characterized by age-related decrease of reserve capacity of various systems and lack of resilience to stressors [ 3 ].…”

Exercise Training: The Holistic Approach in Cardiovascular Prevention

“…Before starting an exercise training program, a functional assessment (preferably using cardiopulmonary exercise testing) is indicated [148]. However, frail patients with CV diseases should be carefully evaluated by using specific tools [149][150][151][152][153][154] and exercise capacity (measured as peak VO 2 at CPET) in two groups [159]. Furthermore, interval training showed favourable ventricular remodelling, in addition to exercise capacity improvement, in patients with recent myocardial infarction [158] A systematic review including 23 studies and 1117 patients (547 received high intensity interval training and 570 received moderate continuous training or usual care), investigated interval training safety in CV diseases patients [160].…”

“…Before starting an exercise training program, a functional assessment (preferably using cardiopulmonary exercise testing) is indicated [ 148 ]. However, frail patients with CV diseases should be carefully evaluated by using specific tools [ 149 – 154 ]. Moderate continuous aerobic training is the oldest and most studied training modality [ 155 , 156 ]; performed by using cycling or treadmill for about 20–30 min 2 or 3 times for week, maintaining a moderate intensity during effort (about 60–85% of peak heart rate or 11–14 on Borg scale) [ 148 , 157 ].…”