Frailty, comorbidity, cardiovascular disease burden and quality of life in older patients with non ST elevation acute coronary syndrome managed by invasive strateg

Abstract

Background: Acute coronary syndrome among older patients is associated with increased morbidity and mortality. In developed countries, there is an increase in the number of older patients managed by invasive strategy. Frailty is emerging as an independent marker of adverse cardiovascular outcomes and its prevalence among older patients undergoing invasive treatment in the setting of Non ST Elevation Acute Coronary Syndrome (NSTEACS) is not known. The impact of frailty, co-morbidity and cardiovascular status on cardiovascular outcomes and quality of life in older patients with NSTEACS managed by invasive strategy is not known. Aims: 1. To determine the prevalence of frailty and compare frailty status by Fried and Rockwood Frailty scales 2. To assess adverse cardiovascular outcomes at one month according to frailty status in older NSTEACS patients managed by invasive strategy 3. To assess cardiovascular disease burden in relation to frailty status 4. To assess comorbidity burden according to frailty status and asses its relation to adverse CV outcomes at one month 5. To evaluate cardiac symptom burden and the quality of life in older NSTEACS patients managed by invasive strategy 6. Assess cognitive function in older NSTEACS patients and its association with frailty Methods: This prospective observational study was conducted in Freeman Hospital, Newcastle upon Tyne. The study participants underwent invasive management of NSTEACS as per the guidelines. Fried Frailty Classification (FFC) was used to group patients as frail (F), pre-frail (PF) and robust (R); and Rockwood Frailty Classification (RFC) grouped patients as frail (F) and non-frail (NF). Charlson co-morbidity index was calculated to quantify co-morbidity burden. To assess the cognitive status of patients during admission, the Montreal Cognitive Assessment was utilised. Arterial stiffness, peripheral arterial tonometry, carotid intima media thickness (CIMT) and left ventricular function were evaluated for cardiovascular status assessment. Quality of life was assessed using Short Form 36 and EuroQoL questionnaires. All these assessments ii were done prior to invasive management. Procedural complications, in-hospital complications and cardiovascular outcomes at 30 days were recorded. Results: Frailty was three times more common by FFC (30.8%) tool compared to RFC (10.1%). There was no significant difference by frailty status in adverse CV outcomes, in-hospital (9.6% vs. 4.2% vs. 2.2%, p=0.157 for F vs. PF vs. R by FFC and 4.2% vs. 5.6%, p=1.0 for F vs. NF by RFC) and at 30-days (11.0% vs. 5.9% vs. 4.3%, p=0.302 and 8.3% vs. 7.0%, p=0.685 respectively). Measures of arterial stiffness, endothelial dysfunction and CIMT did not vary between the patient groups. LV systolic function was similar in frail patients, but increased E/e’ was noted in frail patients suggestive of diastolic dysfunction. Frail patients had worsening dyspnoea severity by both frailty classifications but angina was worse in frail patients by RFC alone. Higher comorbidity burden was noted in frail patients by both FFC (43.8% vs. 24.6% vs. 13.0%, p=0.001 respectively) and RFC (54.2% vs 25.4%, p=0.007) but did not have an association with rate of adverse CV outcomes. Subclinical cognitive impairment was more common in frail patients by Fried (67.2 % vs. 39.6% vs. 42.2%, p=0.002) and Rockwood (86.4% vs. 31.8%, P<0.001) classification. Physical components of QoL measures by EQ5D and SF-36 were lower in frail patients by both frailty classification but mental component by SF-36 was lower in frail patients by RFC only. Conclusion: Frailty was common among older patients with NSTAECS managed by invasive treatment strategy and the prevalence of frailty varied according to the assessment tool used. Frailty was not associated with short-term adverse CV outcomes, but long-term outcomes need to be studied. Higher comorbidity burden, subclinical cognitive impairment and poor QoL measures were more prevalent in frail patients. Vascular status measures like arterial stiffness, endothelial dysfunction and CIMT were not associated with frailty. Dedicated frailty assessment tool for older patients with coronary artery disease need to be developed. Frail patients may stand to benefit more from contemporary management strategy in the short term and frailty should not preclude them from being offered invasive treatment for coronary artery disease.