Ayyaz Sultan

Role of frailty assessment in patients undergoing cardiac interventions

Average life expectancy is increasing in the western world resulting in a growing number of frail individuals with coronary heart disease, often associated with comorbidities. Decisions to proceed to invasive interventions in elderly frail patients is challenging because they may gain benefit, but are also at risk of procedure-related complications. Current risk scores designed to predict mortality in cardiac procedures are mainly based on clinical and angiographic factors, with limitations in the elderly because they are mainly derived from a middle-aged population, do not account for frailty and do not predict the impact of the procedure on quality of life which often matters more to elderly patients than mortality. Frailty assessment has emerged as a measure of biological age that correlates well with quality of life, hospital admissions and mortality. Potentially, the incorporation of frailty into current risk assessment models will cause a shift towards more appropriate care. The need for a more accurate method of risk stratification incorporating frailty, particularly for elderly patients is pressing. This article reviews the association between frailty and cardiovascular disease, the impact of frailty on outcomes of cardiac interventions and suggests ways in which frailty assessment could be incorporated into cardiology clinical practice.

Impact of frailty on outcomes after percutaneous coronary intervention: a prospective cohort study

Background Average life expectancy is rising, resulting in increasing numbers of elderly, frail individuals presenting with coronary artery disease and requiring percutaneous coronary intervention (PCI). PCI can be of value for this population, but little is known about the balance of benefit versus risk, particularly in the frail. Objective To determine the relationship between frailty and clinical outcomes in patients undergoing PCI. Methods Patients undergoing PCI, for either stable angina or acute coronary syndrome, were prospectively assessed for frailty using the Canadian Study of Health and Ageing Clinical Frailty Scale. Demographics, clinical and angiographic data were extracted from the hospital database. Mortality was obtained from the Office of National Statistics. Results Frailty was assessed in 745 patients undergoing PCI. The mean age of patients was 62±12 years and 70% were males. The median frailty score was 3 (IQR 2–4). A frailty score ≥5, indicating significant frailty, was present in 81 (11%) patients. Frail patients required longer hospitalisation after PCI. Frailty was also associated with increased 30-day (HR 4.8, 95% CI 1.4 to 16.3, p=0.013) and 1 year mortality (HR 5.9, 95% CI 2.5 to 13.8, p<0.001). Frailty was a predictor of length of hospital stay and mortality, independent of age, gender and comorbidities. Conclusions A simple assessment of frailty can help predict mortality and the length of hospital stay, and may therefore guide healthcare providers to plan PCI and appropriate resources for frail patients.

Pronounced increase in risk of acute ST-segment elevation myocardial infarction in younger smokers

Objectives Previous studies have shown that smokers presented with ST-segment elevation myocardial infarction (STEMI) a decade earlier than non-smokers. However, no account has been made for population smoking trends, an important deficit addressed by this study. Methods The combination of admission data on patients with acute STEMI undergoing percutaneous coronary intervention and demographic data supplied by the Office for National Statistics for the South Yorkshire population between 2009–2012 were analysed to generate incidence rates and rate ratios (RR) to quantify the relative risk of STEMI from smoking, overall and by age group. Results There were 1795 STEMI patients included of which 72.9% were male. 68 patients were excluded as they had no smoking status recorded, leaving 48.5% of the remaining population as current smokers, 27.2% ex-smokers and 24.3% never smokers. Smokers were over-represented with overall smoking prevalence in South Yorkshire calculated at 22.4%. The incidence of STEMI in smokers aged under 50, 50–65 and over 65 years was 59.7, 316.9 and 331.0 per 100 000 patient years at risk compared to 7.0, 60.9 and 106.8 for the combined group of ex- and never smokers. This gave smokers under the age of 50 years an 8.47 (95% CI 6.80 to 10.54) increase in rate compared to non-smokers of the same age, with the 50–65 and over 65 age groups having RRs of 5.20 (95% CI 4.76 to 5.69) and 3.10 (95% CI 2.67 to 3.60), respectively. Conclusions Smoking was associated with an eightfold increased risk of acute STEMI in younger smokers, when compared to ex- and never smokers. Further efforts to reduce smoking in the youngest are needed.

A retrospective cohort study of the association between smoking and mortality after acute ST-segment elevation myocardial infarction

Background Several studies have shown a ‘smokers paradox’, where following an acute myocardial infarction, smokers have a paradoxically lower mortality than non-smokers. To date, no large study has investigated this paradox in unselected patients with acute ST-segment elevation myocardial infarction (STEMI) managed by primary percutaneous coronary intervention (PCI) alone. Objectives We aimed to examine the association of smoking status and 1-year mortality in patients who had STEMI managed by primary PCI. Methods This retrospective study included all patients admitted with acute STEMI undergoing primary PCI in a single UK centre from January 2009 to April 2012. The survival status for all patients post-STEMI was obtained. Differences in survival by smoking status were assessed using a Kaplan-Meier curve, and after adjustment for age, gender and additional cardiovascular risk factors using a Cox regression analysis. Results The 1-year mortality for patients with STEMI was 149/1796 (8.3%). There were 846/1796 (47.1%) current smokers, 476/1796 (26.5%) ex-smokers and 417/1796 (23.2%) never smokers. Current smokers were approximately 10 years younger than ex-smokers and never smokers (p=0.001). A multivariate Cox proportional hazards model found no evidence of an association between mortality and smoking status after adjustment; p=0.23. Compared with never smokers, the HR (95% CI) for 1-year mortality for current smokers was 1.47 (0.90 to 2.39) and 1.08 (0.66 to 1.77) for ex-smokers. Conclusions In this retrospective cohort study, we found no evidence of an association between mortality and smoking status in patients with acute STEMI treated with PCI, and thus no evidence of a ‘smokers paradox’.

A retrospective cross-sectional study on the association between tobacco smoking and incidence of ST-segment elevation myocardial infarction and cardiovascular risk factors

Background Cigarette smoking is a well-established risk factor for the development of coronary heart disease. However, the relationship between smoking and acute ST-segment elevation myocardial infarction (STEMI) is less well described. Objective To determine the relative risk of acute STEMI in smokers and ex-smokers, compared with individuals who had never smoked. Methods This observational study studied all patients with STEMI undergoing percutaneous coronary intervention (PCI) in South Yorkshire, UK from 1 January 2009 to 6 April 2012. Additional contemporary demographical data for the South Yorkshire population, supplied by the Office for National Statistics, allowed derivation of the incidence rate of STEMI in South Yorkshire—both overall and stratified by smoking status. Incidence rate ratios and population attributable risk (PAR) were calculated to quantify STEMI risk. Results There were 1715 STEMIs in 1680 patients during the study period. Smoking status was obtained in 96.2% patients. The prevalence of smoking was 47.3% in patients with STEMI and 22.0% in the general population. In patients with STEMI, smokers were ∼10 years younger, mean (SD) 57.2 (11.1) years, than never-smokers, 66.4 (12.1) years, and ex-smokers, 67.9 (11.9) years. The age-standardised incident rate ratio of STEMI was 5.2 (4.5–6.1) for current smokers and 1.1 (1.0–1.3) for ex-smokers, with the reference group being never-smokers for both. Almost 50% of STEMIs were attributable to smoking (PAR=48.3%). Conclusion Cigarette smoking is associated with a fivefold increased risk of STEMI. Smoking cessation reduced this risk to a level similar to never-smokers.

77 Impact of Frailty on Length of Hospital Stay After Percutaneous Coronary Intervention

Background Average life expectancy is rising, resulting in a higher proportion of elderly individuals being treated for coronary artery disease with percutaneous coronary intervention (PCI). PCI has benefits for this population but relatively little is known about the balance of benefit versus risk. Current PCI risk scores, such as the New York risk score, are poor predictors for elderly patients who are often frail and suffer significant comorbidities. Objective To determine the relationship between frailty and length of hospital stay for patients undergoing PCI. Methods Patients undergoing PCI at the South Yorkshire Cardiothoracic Centre, Sheffield, between March 2012 and January 2013, were prospectively assessed for frailty using the Canadian Study of Health and Ageing Clinical Frailty Scale (1–9, where 1 is extremely fit and 9 is pre-terminal). Patient demographics, clinical features and angiographic results were extracted from the hospital database. Mortality was obtained from the Office of National Statistics. Length of stay data were collected from hospital record as the primary outcome. Results Frailty assessment was completed for 602 patients undergoing PCI. The median (with interquartile range) age of patients was 63 years (54–70), the frailty score was 3 (2–4) and 70.3% were males. Of these, 62 (10.3%) were deemed truly frail (frailty score of 5–7). Length of stay data were available for 576 patients. On multivariate analysis the independent risk factors for frailty were older age, female gender, hypertension, extent of coronary artery disease and the Charlson comorbidity index. Total length of stay significantly increased with increasing levels of frailty (Figure 1). The frailty score was a significant risk factor for increased length of stay, independently to age and the New York PCI risk score. Abstract 77 Figure 1 Median length of hospital stay (with interquartile range) for patients who were not frail was 3 days (2–6) and for those who were frail it was 5 days (3–14). This was statistically significant, Mann-Whitney U test p-value <0.001 Conclusions A simple assessment of frailty can help predict the length of hospital stay, and may therefore help clinicians and managers plan PCI and appropriate resources for vulnerable patients.

The first reported case of a retained epicardial pacing wire causing coronary artery compression and out-of-hospital cardiac arrest

A 55-year-old female underwent therapeutic hypothermia for an out-of-hospital cardiac arrest (OHCA) due to VF which was successfully defibrillated by paramedics. Seven months earlier, this patient had undergone an elective surgical prosthetic aortic valve replacement for severe aortic stenosis. She underwent coronary angiogram (CAG) with a view to subsequent implantation of an internal cardiac defibrillator. CAG …

SMOKING STATUS AND MORTALITY FOLLOWING ACUTE ST-SEGMENT ELEVATION MYOCARDIAL INFARCTION: TIME TO DISMISS THE SMOKER’S PARADOX

The “smoker’s paradox”, where smokers have improved survival post-myocardial infarction, has been observed in numerous studies. To date, no large study has investigated the existence of the smoker’s paradox in the era of invasive therapy in unselected patients with acute ST-segment elevation

NO EVIDENCE TO SUPPORT THE EXISTENCE OF A SMOKER’S PARADOX IN ACUTE ST-SEGMENT ELEVATION MYOCARDIAL INFARCTION MANAGED BY PRIMARY PERCUTANEOUS CORONARY INTERVENTION

Several studies have shown that in acute coronary syndrome, smokers have a lower mortality than non-smokers. This has been referred to as the “smoker’s paradox”. However, to date, no large, single-centre registry study involving patients with acute ST-segment elevation myocardial infarction (

IMPACT OF CIGARETTE SMOKING ON THE QUANTATIVE RISK OF DEVELOPING ACUTE ST-SEGMENT ELEVATION MYOCARDIAL INFARCTION AND THE SUBSTANTIAL BENEFIT OF SMOKING

Cigarette smoking is a well-established risk factor for the development of coronary heart disease. However, the relationship between smoking and acute ST-segment elevation myocardial infarction (STEMI) is less well described. In the UK, the Department of Health reports that over a third of smokers