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Improved outcomes after invasive strategy in frail Non-ST-Elevation Myocardial Infarction patients
Session:
Painel 7 -Doença Coronária 5
Speaker:
André Azul Freitas
Congress:
CPC 2020
Topic:
E. Coronary Artery Disease, Acute Coronary Syndromes, Acute Cardiac Care
Theme:
13. Acute Coronary Syndromes
Subtheme:
13.4 Acute Coronary Syndromes – Treatment
Session Type:
Posters
FP Number:
---
Authors:
André Azul Freitas; Guilherme Pessoa-Amorim; Helder Santos; Diogo Santos Ferreira; Adriana Belo; Cristina Gavina; Rui Baptista; Sílvia Monteiro; Em nome dos investigadores do Registo Nacional de Síndromes Coronários Agudos
Abstract
<p>Introduction: Frailty is common among patients presenting with non-ST-elevation myocardial infarction (NSTEMI), who have conflicting risks regarding benefits and harms of invasive procedures. We aimed to assess the clinical management and the prognostic impact of invasive procedures in frail NSTEMI patients.</p> <p>Methods: We included 6602 NSTEMI episodes recorded from 2010-2019 in a multicentre registry. A validated deficit-accumulation model was used to create a frailty index (FI) comprising 22 clinical features (not including age). Frailty was initially defined as FI>0.25.</p> <p>Results: A total of 1763 (26.4%) NSTEMI patients were considered frail. Guideline-recommended in-hospital medical therapy (including aspirin, P2Y12 inhibitors, dual-antiplatelet therapy, heparin/heparin-related agents, and statins) was less commonly used in frail patients. Coronariography, percutaneous coronary intervention (PCI) and coronary artery bypass surgery were less frequently performed in frail patients (p<0.001). Delayed coronariography was more common in frail patients (p<0.001), and radial access was less commonly used (p<0.001). At discharge, frail patients were less often offered aspirin, P2Y12 inhibitors and lipid-lowering therapy other than statins, and more often prescribed with anticoagulants. Frail patients had increased in-hospital stay, all-cause and cardiovascular (CV) death, as well as 1-year all-cause death and all-cause and CV hospitalization (p<0.001). Receiver-operator-characteristics curve analysis identified 0.20 as the best FI cutoff to predict all-cause 1-year mortality (area under the curve: 0.702; p<0.001) – this cutoff was subsequently used to define frailty. Although frailty status modified in-hospital risk reduction from coronariography and PCI (Wald test p<0.05), their long-term prognostic benefit remained unaffected (Wald test p>0.05). In a multiple regression model, coronariography and PCI were associated with reduced in-hospital all-cause and CV death, as well as 1-year all-cause death and all-cause and CV hospitalization, independently of frailty status or GRACE score (p<0.001 for all comparisons).</p> <p>Conclusion: Frail NSTEMI patients are less commonly offered guideline-recommended therapy; however, coronariography and PCI were associated with reduced short- and long-term risk regardless of frailty status or GRACE score. Increased adherence to guideline recommendations might improve clinical outcomes in frail NSTEMI patients.</p>
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