Frail elderly more likely to have major bleeding after acute MI

December 7, 2018

By Will Boggs MD

NEW YORK (Reuters Health) - Frail elderly patients are more likely than non-frail elderly patients to experience major bleeding after acute myocardial infarction (AMI), according to findings from the ACTION Registry.

"We had expected frailty to increase bleeding risk across the board - since patients with acute MI who don't undergo invasive procedures are still treated with anticoagulants and antiplatelet agents which can increase bleeding risk," Dr. John A. Dodson from NYU Langone Health, in New York City, told Reuters Health by email. "But based on our findings, it appears that only those patients undergoing invasive procedures are at increased bleeding risk when frail."

Over half of patients undergoing percutaneous coronary intervention (PCI) in the U.S. are 65 years of age or older, and older adults are at the highest risk of major bleeding associated with dual antiplatelet therapy (DAPT) or triple therapy (DAPT plus oral anticoagulant).

Dr. Dodson and colleagues used ACTION Registry data to investigate the prevalence of frailty, which has been associated with major in-hospital bleeding among AMI patients in some studies, and its association with such bleeding among older adults with AMI.

Among more than 121,000 patients included in the analysis, 83.6% were fit (frailty score=0), 11.1% had mild frailty (frailty score of 1 to 2) and 5.3% had moderate to severe frailty (frailty score of 3 to 6).

Frail patients were more likely to be female and to present with non-ST-elevation MI (NSTEMI) than ST-elevation MI (STEMI) and less likely to undergo diagnostic catheterization, primary PCI in STEMI, or in-hospital PCI in NSTEMI, the researchers report in the November 26 issue of JACC: Cardiovascular Interventions.

The overall in-hospital major-bleeding rate was 7.0% and was significantly higher among those with frailty (9.4% with mild frailty; 9.9% with moderate to severe frailty) than among those who were fit (6.5%).

The increased bleeding rate was evident among patients undergoing cardiac catheterization, but not among those managed conservatively. Bleeding rates were also higher among patients with STEMI (9.5%) than with NSTEMI (5.7%) and among women (8.4%) than among men (6.0%).

In multivariable analyses, the odds of major bleeding among patients who underwent catheterization were 33% higher among those with mild frailty and 40% higher among those with moderate to severe frailty than among those who were fit. Increased bleeding was not associated with frailty among patients managed conservatively.

"I think the main message here for cardiologists is that 'frailty matters,'" Dr. Dodson said. "We've long intuited this, but we now have evidence from multiple studies to back it up. So it's important to know about frailty as a risk factor in cardiac patients, and moving forward we need to agree as a community on standardized tools to measure it."

"For frail patients, bleeding avoidance strategies are critical," he said. "For example, radial access was used in only 1 in 4 frail patients in our study. Randomized trials in older adults have used higher rates of radial access and have found less bleeding. So this seems to be one relatively straightforward way to improve outcomes in our frail patients."

Dr. John A. Bittl from Florida Hospital Ocala, who wrote an accompanying editorial related to this report, told Reuters Health by email, "The assessment of frailty is a critical component of the evaluation of patients with AMI. Radial access should be used for frail patients with AMI who require a cardiac catheterization or percutaneous coronary intervention."

He added, "In advanced frailty, the inability to ambulate independently is a relatively strong contraindication to surgical procedures such as coronary-artery bypass graft surgery or aortic-valve replacement and probably to transcatheter aortic-valve replacement as well."


J Am Coll Cardiol Intv 2018.

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