Frailty Trajectories After Treatment for Coronary Artery Disease in Older Patients

Abstract

Background-Frailty is an independent risk factor for cardiovascular outcomes. However, its trajectory after coronary artery disease treatment is unknown. Methods and Results-Three hundred seventy-four patients undergoing nonemergent cardiac catheterization followed by treatment (ie, 128 coronary artery bypass graft [CABG], 150 percutaneous coronary intervention [PCI], 96 medical therapy only) were observed for 30 months. A frailty index (FI) score was calculated at baseline (before initial treatment) and 6, 12, and 30 months after treatment. Random-effects models compared FI score trajectories by sex, age, and treatment group. Mean baseline FI scores were 0.170, 0.154, and 0.154 for CABG, PCI, and medical therapy only, respectively. FI scores decreased (improved) 6 months after initial treatment, then increased (worsened) at 12 and 30 months (P<0.001 for differences over time). Women had nonsignificantly higher FI scores than men (P=0.097) but followed the same trajectory (P=0.352 for differences over time). In patients aged ≥75 years, FI scores increased postbaseline for CABG and medical therapy only and after 6 months for PCI patients. Patients <75 years assigned to PCI and CABG experienced a sustained frailty reduction, whereas those assigned to medical therapy only showed stable frailty over the 30-month follow-up period (P value for differences over time by age and treatment group=0.041). Conclusions-With coronary artery disease treatment, frailty generally follows a U-shaped trajectory, but the pattern may differ by age and treatment. Further investigation is needed to confirm these observations and determine whether patients might benefit from consideration of frailty status.

Frailty and Cardiovascular Disease

“…Frailty was associated with a longer hospital stay (HR 4.8, 95% CI: 1.4-16.3; p = 0.013), higher 30-day mortality (HR 4.8, 95% CI: 1.4-16.3; p = 0.01), and higher 1-year mortality (HR 5.9, 95% CI: 2.5-13.8; p < 0.001) [76,77]. Importantly, there is evidence that there is no signiicant diference in change in frailty at 30 months between CABG and PCI (p = 0.090) [78]. In patients ≥75 years old treated with either PCI or CABG, there was a signiicantly diferent trajectory in their frailty score at 30 months (0.188 vs. 247, respectively) and at baseline (0.164 vs. 0.189, respectively; p = 0.041).…”

The Road to Frailty Is Paved With Good Intentions

“…Third, clinical applicability of the 53-item FI is hampered by the time required to measure this sheer volume of items, which is >53 because an item may actually represent the composite score of a multiquestion scale (eg, the dichotomized mini-mental status examination score is considered 1 item in the FI, but it represents 19 individual questions). Fourth, frailty was ascertained after a relatively short period of 2.5 to 3.5 years; more frequent short-term follow-up assessments in the study by Freiheit et al 6 would have been of interest to pinpoint the timing and magnitude of the nadir of postprocedural frailty, and more long-term follow-up assessments (>5 years) in the study by Graciani et al 5 would have better captured the insidious manifestations of age-related muscle wasting and weakness. Fifth, given the small absolute changes in frailty measures observed over time, the effect size is difficult to gauge in practical terms; the so-called clinically meaningful change conferring an important increase in mortality and disability has not been explicitly defined for Fried's scale or Rockwood's FI (knowledge gap).…”

“…Individuals may choose to forgo physical activity just as their treating physicians may choose to forgo or gloss over nonpharmacological noninterventional therapies. The downstream effect of these choices, as we have learned from the eloquent work of Graciani et al 5 and Freiheit et al 6 , is accelerated biological aging and frailty. Sedentary older adults with or without comorbid obesity and (pre)diabetes mellitus are at higher risk of developing frailty, and in parallel, are known to be at higher risk of presenting with coronary events and undergoing revascularization procedures.…”

“…4 The third wave, present time, is evolving the use of frailty from a predictive marker to a therapeutic target and a longitudinal outcome measure-as exemplified by the 2 commendable studies published in this issue of Circulation: Cardiovascular Quality and Outcomes. 5,6 Articles, see p 230 and 239…”

“…Even intermediate levels of physical activity were sufficient to be associated with a 40% to 51% decrease in incident frailty, a finding that is consistent with the proven beneficial effects of moderate-intensity physical activity in older adults. 8 In the second study, Freiheit et al 6 conducted a post hoc analysis of the single-center Calgary Cardiac and Cognition Study (3C) encompassing 374 patients undergoing coronary angiography and subsequent surgical, percutaneous, or medical therapy for coronary artery disease with a mean age of 71.4±5.9 years and female proportion of 27%. The exposure variables were age, sex, therapy, and baseline frailty index (FI).…”