Frailty Linked to Higher Bleeding Risk Among Acute MI Patients Undergoing PCI
More use of radial access and avoidance of excess heparin and glycoprotein IIb/IIIa inhibitor dosing may help curb bleeding in this population.
Frailty increases the risk of bleeding by more than 50% in patients with acute MI undergoing PCI, a new study suggests. The researchers say more efforts are needed to use bleeding-reduction strategies, including radial access, which was employed in only one in four frail patients in the study.
“One of the larger messages of this work is that we can actually capture frailty in large registries, which traditionally hasn't been done,” said lead investigator John A. Dodson, MD, MPH (NYU Langone Health, New York, NY), in an interview with TCTMD. “This is one of the first papers that shows that we can quantify frailty and that it is meaningfully associated with outcomes.”
In an accompanying editorial, John A. Bittl, MD (Florida Hospital Ocala, FL), characterizes the findings as a call to action for interventional cardiologists.
“Although prior studies have identified an association between frailty and mortality in patients with acute coronary syndrome, the present study helps to transform the rote recording of frailty from a mere quality metric in the medical record into an actionable diagnosis,” Bittl writes.
He further notes ways in which the findings can be put into practice. “For example, if a frail patient with AMI is at low-moderate risk for poor outcomes, he or she may decide against an invasive procedure if the incremental risk from associated frailty and other age-associated determinants outweighs the benefits of an invasive procedure,” Bittl writes. “Alternatively, a frail person at high risk may be a better candidate for invasive procedures if he or she can undergo a transradial approach.”
An Independent Predictor of Bleeding Risk
For the study, Dodson and colleagues analyzed data on 129,330 acute MI patients age 65 years or older treated at 775 US hospitals participating in the ACTION (Acute Coronary Treatment and Intervention Outcomes Network) Registry in 2015 and 2016.
Frailty was determined according to impairments in walking, cognition, and activities of daily living. Within each of those domains, patients were scored from 0 to 2. A summary variable was then created to define three categories of frailty: 0 (fit/well), 1 to 2 (vulnerable/mild), and 3 to 6 (moderate to severe). Overall, 16.4% of patients had some level of frailty. Compared with fit/well patients, those who had some degree of frailty were older and more often female.
Patients with vulnerable/mild frailty and those with moderate-to-severe frailty were less likely than fit/well patients to undergo PCI for STEMI (88.8% and 78.2% vs 91.6%; P < 0.001). The same was true for PCI for NSTEMI. Similarly, radial access was used in 31% of fit/well patients compared with 28.4% and 19.1% of vulnerable/mild and moderate-to-severe frailty patients, respectively.
While there was no difference in major bleeding among the three groups when patients were managed conservatively, those who had interventions had greater bleeding with increasing degree of frailty (6.5% in patients who were fit/well, 9.4% in patients with vulnerable/mild frailty, 9.9% in patients with moderate-to-severe frailty). On multivariable analysis, both frailty categories were independently associated with greater risk for PCI-related bleeding compared with the fit/well group.
Dodson and colleagues also found that approximately 50% of all patients, regardless of frailty status, were given excessive doses of unfractionated heparin or low-molecular-weight heparin. Compared with patients who were not excessively dosed, those who were had higher rates of in-hospital major bleeding (8.1% vs 6.2%; P < 0.001). Excess glycoprotein IIb/IIIa inhibitor also was an issue, with approximately 12% of all patients being given excessive doses. Similarly, those patients were more likely than those not given excess glycoprotein IIb/IIIa inhibitor to experience major bleeding (18.5% vs 10.0%; P < 0.001).
After adjusting for known bleeding risk factors, vulnerable/mild frailty and moderate-to-severe frailty were both found to be independently associated with increased bleeding risk. Additionally, there was a statistically significant interaction between frailty and catheterization (P < 0.001).
Focus on Identifying and Incorporating Frailty
“One of the take-home messages is that when we're considering patients for these procedures, frailty is an important thing to know and to inform patients about,” Dodson said. “There’s no question anymore that it matters in terms of outcomes.”
Bittl notes that while there are at least 35 tools available to help clinicians identify frailty, it typically is diagnosed in one of two ways: either the ‘eyeball test’ or via a questionnaire.
“Because frailty mimics the effects of medical conditions, such as heart failure, diabetes, and Parkinson disease, diagnosis is challenging,” he writes.
Dodson agreed, noting that coming up with a validated frailty measure that everyone can agree on is no easy task. Many experts do agree, he added, that a gait-speed test should be recommended in frailty evaluation because it is simple and can be used in just about any setting. “Ideally, the cardiology community would all agree on one measure to use and just use it,” he said.
As for bleeding-reduction strategies, Bittl notes that while radial access can be more technically challenging in older, frail patients than femoral access, the After Eighty study found a 90% success rate with only a 2% rate of bleeding in patients who were at least 80 years of age and who underwent a transradial procedure for ACS.
Bittl also observes that in addition to greater emphasis on attempting radial access and dose-adjusting antithrombotic therapies in frail patients, physicians should also focus on diet and an exercise prescription, which he noted could help decrease readmission or nursing home placement.
Dodson JA, Hochman JS, Roe MT, et al. The association of frailty with in-hospital bleeding among older adults with acute myocardial infarction: insights from the ACTION registry._ J Am Coll Cardiol Intv._ 2018;11:2287-2296.
Bittl JA. Invasive cardiac procedures increase bleeding in frail patients with acute myocardial infarction: a call to action. J Am Coll Cardio Intv. 2018;11:2297-2299.
- Dodson reports being supported by a Patient Oriented Career Development Award from the National Institutes of Health/National Institute on Aging, and a Mentored Clinical and Population Research Award from the American Heart Association.
- Bittl reports no relevant conflicts of interest.