Frailty Status Improves Prediction of Long-term Outcomes in PCI Patients

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Frail patients who undergo percutaneous coronary intervention (PCI) have elevated risk of mortality and myocardial infarction (MI) at 3 years after their procedure. The results, published online August 30, 2011, ahead of print in Circulation: Cardiovascular Quality and Outcomes, suggest that assessing frailty in addition to traditional risk factors could improve patient management.

Researchers led by Mandeep Singh, MD, MPH, of the Mayo Clinic (Rochester, MN), looked at 628 patients aged 65 years or older discharged after PCI at either the Mayo Clinic or Franciscan Skemp Hospital (La Crosse, WI). While hospitalized, patients were given standardized questionnaires and tests to ascertain frailty (Fried criteria), comorbidity (Charlson index), and quality of life (Short Form 36 [SF-36]). Subjects also were evaluated using the Mayo Clinic Risk Score, which is based on traditional cardiovascular risk factors such as age, MI history, and serum creatinine level.

Frail Patients Different at Baseline, After Treatment

In all, 18.6% of patients were considered frail, while 47.4% had intermediate frailty, 20% were not frail, and 13.3% were unable to complete the evaluation.

Length of hospital stay was longer for patients with frailty and intermediate frailty than for those without the condition (3.9 ± 3.3 days vs. 2.5 ± 1.9 days; P < 0.001). Three-year mortality rates were 28% for frail patients and 6% for nonfrail patients, while the combined death and MI rates were 41% and 17%, respectively.

After multivariable adjustment, predictors of long-term mortality included frailty, comorbidity, and quality of life. But only frailty was a risk factor for long-term mortality or MI (table 1).

Table 1. Long-term Risk of Adverse Outcomes

^a Per 10-point decrease in the physical component of SF-36.

When frailty, comorbidity, and quality of life were added to the Mayo Clinic Risk Score, 43% of patients moved to a higher risk category, the authors report. The measurements “may further improve the risk stratification for patients undergoing high-risk coronary revascularization procedures,” Dr. Singh and colleagues conclude. “Health status is a recognized priority for patient-oriented research, yet clinicians do not use it. Thus, fostering its purposeful use can improve management by moving the focus of clinical care from the disease to the patient.”

Not only are the tests simple to administer and noninvasive, they “may be useful when counseling patients regarding the risk of worse long-term outcomes in conjunction with traditional risks included in the current PCI models,” the authors write.

Where Research Meets Practice

In a telephone interview with TCTMD, David A. Cox, MD, of Lehigh Valley Hospital (Allentown, PA), described how frailty is assessed in actual practice. “You know it when you see it. You look at somebody and get some sense of if they’re kyphotic and hunched over,” he said. “There’s usually some assessment of mobility and independence.”

Dr. Cox did not foresee many clinicians adopting so many risk scores into regular practice, but he still was struck by how well the paper made its case. “Anytime you see 40% of patients move into a higher risk category that predicts long-term outcome, that sounds like a good fishing lure,” he noted, observing that mortality was found to be 4 times higher in frail vs. nonfrail patients.

In short, “the study supports what good clinicians already know, but better defines for us how important frailty is,” he commented.

The question, said Dr. Cox, is whether it makes sense to encourage the use of formal risk scores, especially given the ongoing discussions about appropriateness criteria for PCI. If clinicians decide to use such scores, it is important that frailty make it into the equation, he stressed.

But it also may make sense to take a simple approach, Dr. Cox advised. “What we need to do as a field is better define which 1 or 2 parameters of frailty we can use easily in clinical practice, rather than just saying, ‘I know it when I see it.’”

Another complicating factor, he noted, is that some of the frailest patients do surprisingly well after PCI. “How much does the coronary disease, if it’s fixable and [the procedure] can be done safely, contribute to the frailty? There’s probably 20% to 25% of people who, if you fix their arteries, their frailty will get better,” Dr. Cox suggested.

Study Details

Frailty was determined to be present if subjects met criteria for 3 or more of the following core elements:

• Unintended weight loss
• Exhaustion
• Physical activity
• Time required to walk 15 feet
• Grip strength

Frail patients tended to be older, were more likely to be female, had higher body mass index, and had a greater number of comorbidities including diabetes, hypertension, chronic lung disease, peripheral artery disease, and chronic kidney disease than those with no or intermediate frailty. Prior heart failure, CABG, and MI also were more common among the frail group. Moreover, nearly a quarter of frail patients had had an unexpected fall within the past 6 months.

Source:

Singh M, Rihal CS, Lennon RJ, et al. Influence of frailty and health status on outcomes in patients with coronary disease undergoing percutaneous revascularization. Circ Cardiovasc Qual Outcomes. 2011;4:496-502.

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