Impact of frailty on 6-months outcome in elderly patients with NSTEMI: The role of intervention and timing

Background

There is currently a paucity of evidence on how to optimally treat elderly patients presenting with non-ST-elevation myocardial infarction (NSTEMI). The EVALUATE-Pilot-Study was designed as a nonrandomized, prospective, single-centre study to evaluate the choice of treatment and 6-months-outcome of patients > 75 years presenting with NSTEMI. Special attention was paid to the functional status, comorbidities and frailty. 

Methods

Consecutive patients ≥ 75 years presenting with NSTEMI to our hospital between 07/17 and 07/18 were included into the EVALUATE-study. Patients were asked to participate and sign informed consent 0 to 2 days after reception. Demographic data, past medical history and present medical condition were documented. During day 0 and day 2 geriatric assessment including clinical frailty scale, Barthel-Index, Charlson comorbidity index, “Timed up and go”-Test, Mini Mental Status Test, Geriatric depression scale, SF-36 (Quality of life), IADL, Killip-Score, Grace-Score and Euro-Score were performed. After 6 months patients were re-evaluated either within a follow-up stay or by a visit at home.

Results

Of 106 patients (mean age 81.9±5.3, 57% male), 68 pts. (64%) were treated with intervention, 38 pts. (36%) conservatively. Patients treated with intervention were significantly younger (80.9±4.7 vs. 83.5±6.0; p=0.02) and had a lower Killip-Score (1.16±0.37 vs. 1.37±0.63, p=0.05). All other demographic variables as well as cardiovascular risk factors, functional status and laboratory parameters were comparable. 

Patients were followed-up after 33±12 weeks if alternate endpoints (death, severe cognitive impairment) had not already been reached. 22 patients (20.8%) were lost to Follow-Up. 

Patients who underwent interventional treatment were less often frail according to Clinical Frailty Scale (CFS ≥ 5 pts; 14% vs. 31%, p=0.05). Additionally, patients who received angiography within the first 72 hours had a significant lower CFS (3.16±1.31 vs. 4.21±2.33, p=0.03). 

At Follow-Up, a significant decrease in the Clinical Frailty Scale (-1.02±1.54, p=0.00) was observed.

Choice of treatment didn’t seem to have an impact on the degree of decrease in frailty (intervention: -0.97±1.48 vs conservative: -1.10±1.68, p=ns). Neither did timing of intervention (within 72hrs: -0.85±1.48 vs. after 72hrs: -1.67±1.37, p=ns).

Conclusion:

In this prospective analysis of consecutive patients > 75 years presenting with NSTEMI, frailty did seem to influence decision-making for therapy planning as well as timing of intervention. 6 months after the acute event, a relevant decrease of frailty was observable. This hints towards an overestimation of frailty status in acute events like an acute coronary syndrome and shows, that treatment leads to an improved functional status of elderly patients. More evidence is needed to gain a better understanding of the interaction of frailty and acute coronary syndromes.