Frailty Independent Risk Factor for Bleeding in AMI

November 20, 2018

Frailty is a strong independent risk factor for major bleeding in older adults with acute myocardial infarction (AMI) managed with an invasive strategy, results of a large American registry study suggest.

After adjustment for potential confounders, frailty was associated with a 30% to 40% higher risk of in-hospital bleeding in patients who underwent cardiac catheterization.

The study was published online November 19 in JACC: Cardiovascular Interventions.

"I think the main message here for cardiologists is that frailty matters. We've long intuited this but we now have evidence from multiple studies to back it up," John A. Dodson, MD, director of the geriatric cardiology program, Leon H. Charney Division of Cardiology, NYU Langone Health and NYU School of Medicine, New York City, told theheart.org | Medscape Cardiology.

"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," write Dodson and colleagues.

This is an "important analysis [that] helps to transform the rote recording of frailty from a mere quality metric in the medical record into an actionable diagnosis," John A. Bittl, MD, Interventional Cardiology Group, Florida Hospital Ocala, writes in an editorial comment.

The ACTION Registry

The study involved 129,330 AMI patients 65 years and older from the Acute Coronary Treatment and Intervention Outcomes Network (ACTION) registry. Frailty was classified on the basis of impairments in three domains: walking (unassisted, assisted, wheelchair/nonambulatory), cognition (normal, mildly impaired, moderately/severely impaired), and activities of daily living.

Impairment in each domain was scored as 0, 1, or 2, and a summary variable consisting of three categories was then generated: 0 (fit/well), 1 to 2 (vulnerable/mild frailty), and 3 to 6 (moderate to severe frailty).

Overall, 16.4% of patients had at least some degree of frailty. These patients were typically older, more often female, and less likely to undergo cardiac catheterization than fit/well patients.

Major bleeding increased across categories of frailty, from 6.5% in the fit/well group, to 9.4% in the vulnerable/mild frailty group, to 9.9% in the moderate- to severe-frailty group (P < .001). This pattern was noted in patients undergoing catheterization but not in those managed conservatively.

Among the patients who underwent catheterization, both frailty categories were independently associated with an increased risk of major bleeding, compared with the nonfrail group.

Risk of Bleeding by Frailty Category
  Adjusted Odds Ratio (95% Confidence Interval)
Strategy Vulnerable/Mild Frailty Moderate/Severe Frailty
Catheterization 1.33 (1.23–1.44) 1.40 (1.24–1.58)
No catheterization 1.01 ( 0.86–1.19) 0.96 (0.81–1.14)

No association was found between frailty and bleeding risk in patients managed conservatively (vulnerable/mild frailty adjusted OR, 1.01; 95% CI, 0.86 - 1.19; moderate to severe frailty adjusted OR, 0.96; 95% CI, 0.81 - 1.14).

Actionable Steps

Paradoxically, note the researchers, despite being at higher bleeding risk, frail patients were less likely to receive strategies known to reduce bleeding. For example, only one in four frail patients (26%) received radial access, despite several studies showing that radial access significantly lowers bleeding risk, including a large meta-analysis published in 2016.

The researchers say another important finding is that one-half of patients (both frail and nonfrail) received an excess initial heparin or low-molecular-weight heparin bolus, and 12% received excess glycoprotein IIb/IIIa inhibitor doses.

Dodson sees two "actionable steps" from this research. The first is to make efforts to quantify frailty beyond the "eyeball test" — simply looking at a patient — which can be inaccurate, he told theheart.org | Medscape Cardiology.

"Our study used a combination of variables abstracted from the medical record: walking impairment, cognitive impairment, and activity of daily living impairment. If people were to measure a single component moving forward, walking speed is something that's easily obtained and reproducible," he explained.

The second is that bleeding avoidance strategies are "critical" in frail elderly. "This seems to be one relatively straightforward way to improve outcomes in our frail patients," said Dodson.

Bittl agrees. Based on these observations, "clinicians should consider using radial access and dose adjustment of antithrombotic therapies in frail patients with AMI who need invasive procedures," he writes.

Making the diagnosis of frailty is important for decision-making in older adults with AMI, he writes. "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 suggests.

"Alternatively, a frail person at high risk may be a better candidate for invasive procedures if he or she can undergo a transradial approach. In this way, diagnosing frailty in a patient with AMI facilitates clinical decision-making and helps to personalize an approach to optimize outcomes," he concludes.

The study had no specific funding. Dodson and Bittl have disclosed no relevant financial relationships.

J Am Coll Cardiol Intv. 2018;11:2287-2296. Abstract, Editorial

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