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Invasive strategy increased bleeding risk in frail older AMI patients

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Frailty an ‘actionable diagnosis’ in AMI patients

This analysis is important and has clinical implications beyond those of previous analyses linking frailty to poor outcomes in patients with cardiovascular disease, according to John A. Bittl, MD.

“The present study helps to transform the rote recording of frailty from a mere quality metric in the medical record into an actionable diagnosis,” Dr. Bittl said in an editorial comment on the findings.

Results of the study show an association between invasive cardiac procedures and increased bleeding in frail patients with AMI.

The benefits of an invasive procedure might be outweighed by the incremental risk added by frailty in older AMI patients at low to moderate risk of poor outcomes, Dr. Bittl suggested.

By contrast, frail older AMI patients at high risk for poor outcomes might be better candidates for an invasive procedure if they can undergo a transradial approach, he said, noting that in the study by Dodson and colleagues, only 26% of frail patients received radial access despite randomized trials showing the approach reduces risk of bleeding.

“In this way, diagnosing frailty in a patient with AMI facilitates clinical decision making and helps to personalize an approach to optimize outcomes,” Dr. Bittl concluded.

Dr. Bittl is with the Interventional Cardiology Group, Florida Hospital Ocala (Fla.) He reported no relationships relevant to his editorial comment ( JACC Cardiovasc Interv. 2018 Nov 26;11[2];2297-93 ).



Frail older patients with acute myocardial infarction (AMI) may be at increased bleeding risk if managed with an invasive strategy, results of a large U.S. registry study suggest.

Ingram Pub.l

The increased bleeding risk was seen among frail older AMI patients who underwent cardiac catheterization, but it was not seen in those treated with more conservative medical management, according to study results.

That finding highlights the conundrum with invasive management strategies for frail patients with AMI, wrote John A. Dodson, MD, MPH, of New York University and study coinvestigators.

“Awareness of vulnerability and greater utilization of evidence-based strategies to reduce bleeding, including radial access and properly dose-adjusted anticoagulant therapies, may mitigate some bleeding events,” they wrote in JACC: Cardiovascular Interventions.

Results of this study, the first large U.S. registry analysis evaluating in-hospital bleeding risk in frail older adults with AMI, confirm findings from several previous small cohort studies linking frailty in AMI patients to in-hospital bleeding, investigators reported.

The analysis included a total of 129,330 AMI patients in the ACTION (Acute Coronary Treatment and Intervention Outcomes Network) registry who were aged at least 65 years in 2015 or 2016.

About one in six of these older patients were frail, as defined by a composite score based on impaired walking, cognition, and activities of daily living, investigators reported.

The bleeding rate was significantly higher among frail patients undergoing cardiac catheterization, at 9.4% for patients rated as having vulnerable/mild frailty and 9.9% for patients with moderate to severe frailty (P less than.001), compared with fit/well patients, whose rate was 6.5%, investigators wrote. By contrast, there was no significant difference in bleeding rates for frail versus nonfrail patients managed conservatively, they said.

After adjusting for bleeding risk factors, frailty was independently associated with increased risk of bleeding, compared with fit/well status, with odds ratios of 1.33 for vulnerable/mild frailty and 1.40 for moderate to severe frailty. Again, no association was found between frailty and bleeding risk in patients managed conservatively, according to investigators.

Frail patients in the ACTION registry were more often older and female and less likely to undergo cardiac catheterization when compared with fit or well patients, they added in the report.

Like the small cohort studies that preceded it, this large U.S. registry study shows that frailty is an “important additional risk factor” among older adults with AMI who are managed with an invasive strategy, investigators said.

“When applicable, estimation of bleeding risk in frail patients before invasive care may facilitate clinical decision making and the informed consent process,” they wrote.

The ACTION registry, an ongoing quality improvement initiative sponsored by the American College of Cardiology and the American Heart Association, started collecting frailty characteristics among hospitalized AMI patients in 2015, investigators noted.

Dr. Dodson reported support from the National Institutes of Health/National Institute on Aging and from the American Heart Association. Study coauthors provided disclosures related to Bayer, Janssen, Abbott Vascular, Jarvik Heart, LifeCuff Technologies, and Ancora Heart. JACC Cardiovasc Interv. 2018 Nov 26;11:2287-96

SOURCE: Dodson JA et al. JACC Cardiovasc Intv. 2018;11:2287-96.

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