Invasive Strategy in Frail Patients Is Safe

Courtesy of Dr. Carlos Fava.

The current population of frail and elderly patients is increasing, and while non-ST-segment acute coronary syndrome (NSTEACS) guidelines recommend early invasive treatment, this group has been excluded from most studies on the subject.

Current information on its efficacy is controversial but agrees with the notion that this is a higher-risk group with higher rates of complications, hospital stay, and cost increase.

The prospective LONGEVO-SCA registry included 44 sites in Spain.

It took into account patients who were ≥80 years old and presented NSTEACS. This population was subjected to tests to determine frailty, disability, cognitive status, nutritional status, and comorbidities. Subjects who were unable to complete the tests or who refused to participate were excluded from the study.

Read also: Early Invasive Strategy Benefits High-Risk Patients.

The primary endpoint at 6 months was a composite of cardiac death, recurrent infarction, or unplanned coronary revascularization.

The study enrolled 531 patients. Among them, 407 were subjected to invasive strategy (76.6%). Mean patient age was 84.3 years old. No differences were observed regarding risk factors such as diabetes, hypertension, body mass index, peripheral vascular disease, elevated troponin levels, frailty, and high GRACE score values.

Patients who underwent an invasive strategy were younger. Most of them were male, presented less comorbidities, lower heart rate, and lower GRACE score values. They also presented a better nutritional status, higher results in cognitive tests, and a lower degree of frailty.

Read also: Should Sex Be Taken into Account with Left Main Coronary Artery Revascularization?

No differences regarding in-hospital clinical course were observed, except for a higher index of atrial fibrillation in patients managed conservatively and a higher need for diuretics after discharge.

The primary endpoint at 6 months was higher with the conservative strategy (26.6% vs. 11.5%; subhazard ratio [sHR]: 2.66; 95% confidence interval [CI]: 1.71-4.13; p < 0.001), a trend that remained after adjusting for confounding variables.

The primary endpoint was associated with older age, diabetes, prior infarction, prior heart failure, lower hemoglobin levels, lower creatinine clearance, lower ejection fraction, and prior bleeding.

The success of the invasive strategy was inversely related to frailty status.

Conclusion

An invasive strategy was independently associated with better outcomes in elderly patients with NSTEACS. This association was different according to frailty status.

Editorial Comment

An invasive strategy has proven to be greatly beneficial in NSTEACS for years now. However, we are currently faced with a new challenge: elderly and frail patients.

This is one of the few registries that, with its limitations, show us that the use of invasive strategy in these patients is feasible and safe. However, limitations are brought about by, on the one hand, the level of frailty, cognitive status, and nutritional status, and, on the other hand, operator and hospital experience in the treatment of this complex population.

Courtesy of Dr. Carlos Fava.

Original title: Invasive Strategy and Frailty in Very Elderly Patients with Acute Coronary Syndromes.

Reference: Isaac Llaó et al. EuroIntervention 2018;14:e336-e342.

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