番茄社区

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Older frail acute myocardial infarction (AMI) patients face a higher risk of in-hospital bleeding than young, non-frail patients, a registry study found.

In-hospital major bleeding rates were 6.5% for fit/well patients, 9.4% for vulnerable/mild frailty patients, and 9.9% for moderate-to-severe frailty patients (P<0.001), reported John Dodson, MD, MPH, of New York Langone Health in New York City, and colleagues in .

Among catheterized patients, any degree of frailty was independently associated with bleeding risk (vulnerable/mild frailty adjusted OR 1.33, 95% CI 1.23-1.44; moderate-to severe frailty adjusted OR 1.40, 95% CI: 1.24-1.58).

There was no relationship between frailty and bleeding for 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).

Major bleeding events encompassed a hemoglobin decrease of 4 g/dL or more, intracranial hemorrhage, retroperitoneal bleed, any blood transfusion with baseline hemoglobin at least 9 g/dL, transfusion with hemoglobin under 9 g/dL and a potential bleeding event.

Previous papers have found that for patients with acute coronary syndrome there was an association between frailty and mortality, noted John Bittl, MD, of Florida Hospital in Ocala, in.

The new findings "help to transform the rote recording of frailty from a mere quality metric in the medical record into an actionable diagnosis," Bittl wrote.

Previous research had looked at small cohorts of patients with AMI, and large cardiovascular trials have been ineffective in capturing it, making it difficult to confirm the results of studies done on smaller groups, the researchers noted.

These findings are very important considering that frailty is not well collected or evaluated in trials, noted Roxana Mehran, MD, of Mount Sinai Hospital in New York City, who was not involved in the study. "This trial underlines the importance of going beyond traditional demographics, and focusing on this important risk factor in evaluating patients in general."

"Bleeding risk in this population is notable, and should be evaluated as an important parameter in risk calculators. This will require prospective collection of frailty, evaluating bleeding and incorporating it into the risk score and then validating this," Mehran told 番茄社区.

Of the 129,330 AMI patients in the study (mean age ≥ 65 years) seen at 775 U.S. hospitals, 7.0% of the population had the primary outcome of in-hospital major bleeding and 16.4% were frail to some degree.

The patients' frailty was grouped into categories depending upon their impairments in walking (unassisted, assisted, wheelchair/non-ambulatory), cognition (normal, mildly impaired, moderately/severely impaired), and activities for daily living.

The impairment for each category was scored as 0, 1, or 2 and then pooled into a summary variable classified as fit/well (no impairment across categories), vulnerable/mild frailty (a score of 1-2), or moderate-to-severe frailty (a score of 3-6).

The investigators reported that radial access was used instead of femoral access in 19.1% of moderate-to-severe frailty patients, 28.4% of mild frailty patients, and 31.0% among well or fit patients.

"Clinicians should consider using radial access and dose adjustment of antithrombotic therapies in frail patients with AMI who need invasive procedures," Bittl noted.

The findings showed that bivalirudin (Angiomax) was less commonly used in treating moderate-to-severe frailty patients (13.6%) and mild frailty patients (20.0%) than for fit or well patients (28.4%).

For patients undergoing cardiac catheterization, the rate of major bleeding was 6.4% for fit or well patients, 10.3% for vulnerability/mild frailty patients, and 13.6% for moderate-to-severe frailty patients (P<0.001). For patients managed conservatively, the rate of major bleeding was 7.4% for fit/well, 7.0% for vulnerable/mild frailty, and 6.7% for moderate or severe frailty (P=0.38).

The overall rate of in-hospital major bleeding for AMI subgroups was 9.5% for STEMI patients, 5.7% for non-STEMI, 8.4% for women, and 6.0% for men.

For cardiac catheterization patients, bleeding events were 30.3% for fit/well patients, 33.2% for vulnerable/mild frailty patients, and 31.6% for moderate or severe frailty patients (P=0.36).

In-hospital major bleeding rates were 8.1% for the 52% of patients that had excessive dosing of unfractionated heparin or low molecular weight heparin versus 6.2% for those with no excessive dosing (P<0.001).

Excessive dosing of glycoprotein inhibitors was more likely among more frail patients, at 10.9% for fit/well patients, 22.3% for vulnerable/mild frailty patients, and 26.7% for moderate-to-severe frailty patients (P<0.001).

Major bleeding was more common for patients that received excess glycoprotein inhibitor by comparison to those that did not (18.5% vs 10.0%; P<0.001).

Looking ahead, "formal evaluation of frailty in older adults with AMI may assist with informed decision making about the risks and benefits of invasive therapies," the researchers concluded.