Greater Frailty Means More Complications, Higher Mortality After PCI

Frailty is common among older patients undergoing PCI in the United States, and the more severe it is, the greater the likelihood of complications and of dying in the hospital, data from the CathPCI registry shows.

Greater frailty was also tied to poorer PCI results irrespective of patients’ bedside mortality score, lead authors Benjamin Peterson, MD (St. Elizabeth Healthcare, Edgewood, KY), and Ajar Kochar, MD (Brigham and Women’s Hospital, Boston, MA), and colleagues report in a study published online ahead of the June 24, 2025, issue of the JACC.

Looking for frailty in a more routine way may help refine the shared decision-making process around PCI, they say.

Indeed, it’d be a good idea to incorporate some type of frailty assessment into risk scores, particularly when treating older patients, Deepak Bhatt, MD (Mount Sinai Fuster Heart Hospital, Icahn School of Medicine at Mount Sinai, New York, NY), senior author of the study, told TCTMD.

“It might help in some cases also to mitigate against age bias” and prevent clinicians from assuming what older patients might want in terms of their care, he added. “Assessing frailty puts some objectivity to it.”

‘Strikingly High’ Mortality in Some Scenarios

More than half of PCIs are performed in patients older than 65 years, a group that also accounts for a disproportionate share of PCI mortality (about 80%). There are, however, limited data on the prevalence of frailty in this population.

To explore this, the investigators examined data from the CathPCI registry, part of the American College of Cardiology’s National Cardiovascular Data Registry (NCDR). The analysis included more than 1.3 million patients 65 years or older (mean age 74.6 years; 34% women) who underwent PCI between October 2018 and December 2021.

Patients were divided into four groups according to their score on the Canadian Study of Health and Aging Clinical Frailty Scale (CFS), which assesses impairments in activities of daily living like bathing and dressing as well as instrumental activities of daily living like using a telephone, driving, and managing medications:

• Nonfrail (CFS 1-2): 6.0%
• Prefrail (CFS 3-4): 67.8%
• Frail (CFS 5-6): 21.6%
• Severely frail (CFS 7-9): 2.2%

Frail patients tended to be older, were more likely to be women, and were less likely to undergo elective procedures compared with others. The most common PCI indications were NSTEMI in frail patients (47.1%) and STEMI in severely frail patients (40.7%).

Overall, the rate of all-cause mortality in the hospital was 2.4%, ranging from 0.5% in nonfrail patients up to 20.3% in those with severe frailty; rates were 1.1% and 3.3% in the prefrail and frail, respectively.

The relationship between increasing frailty and higher mortality was evident across tertiles of the bedside mortality score and within various clinically relevant subgroups, including those with cardiac arrest, shock, chronic total occlusion (CTO), mechanical support, and severe calcification and those undergoing a left main coronary intervention.

Patients with severe frailty had “strikingly high” mortality rates across complex scenarios, according to the researchers, such as when they underwent PCI in the context of cardiac arrest (44.2%), cardiogenic shock (51.0%), mechanical circulatory support (46.1%), CTO (23.9%), left main occlusion (29.6%), and severe calcification (22.4%).

Rates of various complications, like bleeding, the need for transfusion or new dialysis, vascular problems, and stroke, also consistently went up with greater degrees of frailty.

“These data showing the association of frailty with mortality risk should not justify withholding PCI, especially in acute coronary syndromes,” the investigators stress. “However, frailty status, even prefrailty, strongly influences procedural risk and should inform shared decision-making. Older patients often prioritize independence and avoidance of complications affecting cognition. Increased bleeding risk among frail patients supports guideline recommendations favoring radial access in older adults.”

Eye-opening Results

David Fischman, MD (Jefferson Health, Philadelphia, PA), who was not involved in the study, said the findings are not surprising but could be “eye-opening for those who aren’t aware of this” and should get physicians thinking about how best to care for frailer patients. “Sometimes, we probably do things on frail patients that don’t need to be done, so I think it hopefully will create a conversation in terms of how we should approach these patients,” he said.

Before PCI, interventional cardiologists are likely assessing frailty using “an eyeball test” and not more formal tools, Fischman said, noting that in other scenarios in the cath lab—for structural heart interventions, for instance—it’s more formalized.

These new findings support standardizing the assessment of frailty for PCI as well. “We should be making sure we’re doing the right thing and not just doing it for the sake of doing it,” he said. “I think there should be some type of risk assessment. The problem is there are so many more PCIs and cardiac caths being done, and I’m not sure everybody will take the time to really do a true assessment as you do with the structural heart patient, which is a longer process.”

There’s also a need to perform more research into how accurate clinicians are in assessing frail patients and whether existing tools are the most appropriate for that task, said Fischman.

In an accompanying editorial, John Dodson, MD (New York University Grossman School of Medicine, New York, NY), and Ashok Krishnaswami, MD (Kaiser Permanente San Jose Medical Center, CA), say the routine assessment of frailty in cardiovascular care “is long overdue,” noting that these new findings are in line with prior studies.

“To truly transform care for older adults, we must incorporate frailty testing into routine clinical practice, embedding it as a standard part of every assessment, much like we do for vital signs,” they write.

The editorialists say individualized assessments, ideally involving a multidisciplinary team, are needed to guide clinical decision-making, with that process either bolstering the decision to perform a procedure or leading to a reconsideration. They also tout interventions to prevent or reverse frailty to improve health outcomes before and after PCI.

Finally, Dodson and Krishnaswami call for clinical trials to explore whether frailty can be modified and whether reducing it will influence outcomes in the future. If frailty isn’t modifiable, they say, “determining optimal ways of counseling patients and their caregivers on expected outcomes is of key importance.”

Bhatt, too, said a frailty assessment can help individualize the decision about whether to perform PCI and provide additional information beyond chronological age. “If somebody is 80 and frail, it might not be a wise thing to do an elective PCI on them for angina, whereas if somebody is 90 and not frail, a procedure when indicated, such as PCI in the right setting, could be quite reasonable.”