Prospective assessment of a palliative care tool to predict one-year mortality in patients with acute coronary syndrome

Moretti, Claudio; Iqbal, Javaid; Murray, Scott A; Bertaina, Maurizio; Parviz, Yasir; Fenning, Stephen; Quadri, Giorgio; Gunn, Julian; D’Ascenzo, Fabrizio; Marra, Sebastiano; Moiraghi, Corrado; Riccardini, Franco; Veglio, Franco; Gaïta, Fiorenzo; Denvir, Martin A.

doi:10.1177/2048872616633841

Cited by 12 publications

(9 citation statements)

References 25 publications

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“…Frail patients were prescribed more medications before hospital admission (10.5 ± 2.9 vs. 8.9 ± 3.1 with CFS ≤4, p = 0.003). Index hospitalization was also longer (11)(12)(13)(14)(15)(16)(17)(18)(19)(20)(21)(22)(23)(24) vs. 4 days [IQR 3-7] with CFS ≤4, p < 0.001), but cardiac catheterization was undertaken less frequently in frail patients (33% vs. 81% with CFS ≤4, p < 0.001, Table 2). Observed mortality was higher in frail patients, with 15% dying during the index hospitalization and nearly half by 12 months (48% vs. 9% with CFS ≤4, p < 0.001).…”

Section: Resultsmentioning

confidence: 99%

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Frailty assessment and risk prediction by GRACE score in older patients with acute myocardial infarction

et al. 2020

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Background: Risk prediction after myocardial infarction is often complex in older patients. The Global Registry of Acute Coronary Events (GRACE) model includes clinical parameters and age, but not frailty. We hypothesised that frailty would enhance the prognostic properties of GRACE. Methods: We performed a prospective observational cohort study in two independent cardiology units: the Royal Infirmary of Edinburgh, UK (primary cohort) and the South Yorkshire Cardiothoracic Centre, Sheffield, UK (external validation). The study sample included 198 patients ≥65 years old hospitalised with type 1 myocardial infarction (primary cohort) and 96 patients ≥65 years old undergoing cardiac catheterisation for myocardial infarction (external validation). Frailty was assessed using the Clinical Frailty Scale (CFS). The GRACE 2.0 estimated risk of 12month mortality, Charlson comorbidity index and Karnofsky disability scale were also determined for each patient. Results: Forty (20%) patients were frail (CFS ≥5). These individuals had greater comorbidity, functional impairment and a higher risk of death at 12 months (49% vs. 9% in non-frail patients, p < 0.001). The hazard of 12-month allcause mortality nearly doubled per point increase in CFS after adjustment for age, sex and comorbidity (Hazard Ratio [HR] 1.90, 95% CI 1.47-2.44, p < 0.001). The CFS had good discrimination for mortality by Receiver Operating Characteristic (ROC) curve analysis (Area Under the Curve [AUC] 0.81, 95% CI 0.72-0.89) and enhanced the GRACE estimate (AUC 0.86 vs. 0.80 without CFS, p = 0.04). At existing GRACE thresholds, the CFS resulted in a Net Reclassification Improvement (NRI) of 0.44 (95% CI 0.28-0.60, p < 0.001), largely through reductions in risk estimates amongst non-frail patients. Similar findings were observed in the external validation cohort (NRI 0.46, 95% CI 0.23-0.69, p < 0.001). Conclusions: The GRACE score overestimated mortality risk after myocardial infarction in these cohorts of older patients. The CFS is a simple guided frailty tool that may enhance prediction in this setting. These findings merit evaluation in larger cohorts of unselected patients. Trial registration: Clinicaltrials.gov; NCT02302014 (November 26th 2014, retrospectively registered).

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Section: Resultsmentioning

confidence: 99%

“…GRACE and CFS scores were available for all participants. The recruitment and data collection within this cohort has been previously described in detail [19,20].…”

Section: External Validation Cohortmentioning

confidence: 99%

Frailty assessment and risk prediction by GRACE score in older patients with acute myocardial infarction

et al. 2020

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“…Nevertheless, selection of patients in order to find those who will benefit the most from PMVR and avoid futility is still extremely challenging. In this regard, pre-procedural evaluation of frailty might help to identify those patients with very poor short-term prognosis and those at a higher risk of non-cardiovascular mortality [23] . Although there is extensive evidence of the prognosis impact of frailty in cardiovascular disease, some aspects should be taken into account.…”

Section: Discussionmentioning

confidence: 99%

The prognostic impact of frailty in patients undergoing percutaneous mitral valve repair

Benito‐González¹,

Estévez‐Loureiro²,

Castillo³

et al. 2020

MIS

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Aim: Percutaneous mitral valve repair (PMVR) with MitraClip® has proven to be an effective therapy to reduce mitral regurgitation in patients at high risk for conventional surgery. This population is currently characterized by advance age and high prevalence of comorbidities. Our aim was to evaluate the prevalence of frailty in a cohort of patients undergoing PMVR and its impact on clinical outcomes during follow-up. Methods: A prospective registry was performed including all consecutive patients who underwent elective PMVR between June 2014 and March 2018 in our institution. Frailty was evaluated at admission with the functional FRAIL scale. In-hospital and 30-day procedural outcomes were collected. Clinical follow up was carried out including New York Heart Association (NYHA) functional class, heart failure hospitalization and death. Results: Overall, 70 patients were included (mean age 75.3 ± 9.9 years, 65.7% male). Among them, 27 patients (38.6%) had a pre-procedural FRAIL score greater than 2, meeting frailty criteria. No differences between frail and non-frail patients were found in technical success (P = 1.0) or 30-day device success (P = 0.739). At six months follow up, both groups showed a significant improvement in NYHA functional class compared to baseline (frail: P = 0.002; non-frail: P < 0.001). During a median follow up of 675 (range 416-976) days, frailty patients had a higher incidence of HF admission and all-cause mortality (P = 0.013). In multivariate COX regression analysis, FRAIL score greater than 2 was significantly related to the primary composite endpoint (HR = 2.45; 95%CI: 1.02-5.88; P = 0.044).

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“…Acute coronary syndromes (ACSs) still represent a crucial concern for global health. 1 Registry data show that ACS incidence is higher than three per 1000 patients/year, whereas in-hospital mortality ranges from 2.4% to 14% and first-year mortality can be as high as 30%, 1–3 also as a consequence of the burden of comorbidities.…”

Section: Introductionmentioning

confidence: 99%

“…While it has been observed that shorter DAPT duration reduces bleeding risk, but increases the occurrence of recurrent ischaemic events, evidence coming from a real world setting on optimal DAPT time duration after ACS is still limited. 3–16 The ACS population, known to be at high risk of both ischaemic and bleeding events, is typically underrepresented in randomized controlled trials (RCTs), where less than 50% of enrolled patients had myocardial infarction (MI), and no pre-specified analysis for MI was performed. 3 To complete the picture, clopidogrel, neither prasugrel nor ticagrelor, was the drug of choice in most of these studies, 16,17 even if recent RCTs 11,12 and real world registries 13 demonstrated that DAPT with P2Y12 antagonists such as prasugrel and ticagrelor significantly reduces recurrent ischaemic events compared with clopidogrel-based DAPT regimens, despite the increased bleeding risk.…”

Section: Introductionmentioning

confidence: 99%

Long versus short dual antiplatelet therapy in acute coronary syndrome patients treated with prasugrel or ticagrelor and coronary revascularization: Insights from the RENAMI registry

D’Ascenzo

Bertaina

Fioravanti

et al. 2019

Eur J Prev Cardiolog

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Introduction The benefits of short versus long-term dual antiplatelet therapy (DAPT) based on the third generation P2Y12 antagonists prasugrel or ticagrelor, in patients with acute coronary syndromes treated with percutaneous coronary intervention remain to be clearly defined due to current evidences limited to patients treated with clopidogrel. Methods All acute coronary syndrome patients from the REgistry of New Antiplatelets in patients with Myocardial Infarction (RENAMI) undergoing percutaneous coronary intervention and treated with aspirin, prasugrel or ticagrelor were stratified according to DAPT duration, that is, shorter than 12 months (D1 group), 12 months (D2 group) and longer than 12 months (D3 group). The three groups were compared before and after propensity score matching. Net adverse clinical events (NACEs), defined as a combination of major adverse cardiac events (MACEs) and major bleedings (including therefore all cause death, myocardial infarction and Bleeding Academic Research Consortium (BARC) 3–5 bleeding), were the primary end points, MACEs (a composite of all cause death and myocardial infarction) the secondary one. Single components of NACEs were co-secondary end points, along with BARC 2–5 bleeding, cardiovascular death and stent thrombosis. Results A total of 4424 patients from the RENAMI registry with available data on DAPT duration were included in the model. After propensity score matching, 628 patients from each group were selected. After 20 months of follow up, DAPT for 12 months and DAPT for longer than 12 months significantly reduced the risk of NACE (D1 11.6% vs. D2 6.7% vs. D3 7.2%, p = 0.003) and MACE (10% vs. 6.2% vs. 2.4%, p < 0.001) compared with DAPT for less than 12 months. These differences were driven by a reduced risk of all cause death (7.8% vs. 1.3% vs. 1.6%, p < 0.001), cardiovascular death (5.1% vs. 1.0% vs. 1.2%, p < 0.0001) and recurrent myocardial infarction (8.3% vs. 5.2% vs. 3.5%, p = 0.002). NACEs were lower with longer DAPT despite a higher risk of BARC 2–5 bleedings (4.6% vs. 5.7% vs. 6.2%, p = 0.04) and a trend towards a higher risk of BARC 3–5 bleedings (2.4% vs. 3.3% vs. 3.9%, p = 0.06). These results were not consistent for female patients and those older than 75 years old, due to an increased risk of bleedings which exceeded the reduction in myocardial infarction. Conclusion In unselected real world acute coronary syndrome patients treated with percutaneous coronary intervention, DAPT with prasugrel or ticagrelor prolonged beyond 12 months markedly reduces fatal and non-fatal ischaemic events, offsetting the increased risk deriving from the higher bleeding risk. On the contrary, patients >75 years old and female ones showed a less favourable risk–benefit ratio for longer DAPT due to excess of bleedings.

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Prospective assessment of a palliative care tool to predict one-year mortality in patients with acute coronary syndrome

Abstract: GSF is a multidimensional tool which may be used to identify ACS patients that are at high risk of death and may benefit from end-of-life care.

Cited by 12 publications

References 25 publications

Frailty assessment and risk prediction by GRACE score in older patients with acute myocardial infarction

Frailty assessment and risk prediction by GRACE score in older patients with acute myocardial infarction

The prognostic impact of frailty in patients undergoing percutaneous mitral valve repair

Long versus short dual antiplatelet therapy in acute coronary syndrome patients treated with prasugrel or ticagrelor and coronary revascularization: Insights from the RENAMI registry

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