Eva Bernal

Impact of Frailty and Functional Status on Outcomes in Elderly Patients With ST-Segment Elevation Myocardial Infarction Undergoing Primary Angioplasty: Rationale and Design of the IFFANIAM Study

The IFFANIAM study (Impact of frailty and functional status in elderly patients with ST segment elevation myocardial infarction undergoing primary angioplasty) is an observational multicenter registry to assess the impact of frailty and functional status on outcomes of elderly patients with ST‐segment elevation myocardial infarction (STEMI) undergoing primary angioplasty. STEMI patients age 75 years or older undergoing primary angioplasty will be extensively studied during admission in 4 tertiary care Hospitals in Spain, assessing their baseline functional status (Barthel index, Lawton‐Brody index), frailty (Fried criteria, FRAIL scale [fatigue, resistance, ambulation, illnesses, and loss of weight]), comorbidities (Charlson index), nutritional status (Mini Nutritional Assessment–Short Form), and quality of life (Seattle Angina Questionnaire). Participants will be managed according current recommendations. The primary outcome will be the description of 1‐year mortality, its causes, and associated factors. Secondary outcomes will be functional capacity and quality of life. Results will help to better understand the impact of frailty and functional ability on outcomes in elderly STEMI patients undergoing primary angioplasty, thus potentially contributing to improving their clinical management. Higher life expectancy has resulted in a large segment of elderly population and an increase in myocardial infarction in these patients. This calls attention to healthcare systems to focus on promoting methods to improve the clinical management of this population.

Management of Nonagenarian Patients With Severe Aortic Stenosis: The Role of Comorbidity

BACKGROUND The number of nonagenarian patients with aortic stenosis will likely increase due to the ageing population. We assessed the clinical characteristics, management, and outcomes of nonagenarian patients with severe aortic stenosis. METHODS A total of 177 (117 females and 60 males) consecutive nonagenarian patients from two large contemporary registries were included in this study. Clinical characteristics, comorbidity as assessed by the Charlson Index, clinical management, and outcomes were recorded. The main outcome measure was 1-year mortality. RESULTS The mean patient age was 91.1 years, and 56 patients (31.6%) had a Charlson Index <3. A strong association between comorbidity and 1-year overall mortality was observed, with higher 1-year mortality in patients with Charlson Index ≥3 (66.4% vs. 32.1%, p<0.001). A total of 150 patients (84.7%) were managed conservatively, and 27 (15.3%) underwent transcatheter aortic valve implantation (TAVI). Predictors of a conservative management were treatment out of TAVI centres, lower mean aortic gradient and better functional class. Clinical management was not significantly different with different degrees of comorbidity. A trend toward higher mortality in patients undergoing conservative management was observed (58% vs. 40.7%, p=0.097). Independent predictors of mortality were higher Charlson Index, lower creatinine clearance, lower mean aortic gradient, poorer left ventricular ejection fraction, significant mitral regurgitation and conservative management. CONCLUSIONS About one third of nonagenarians with severe aortic stenosis have few comorbidities. The clinical management was similar irrespective of the Charlson Index. Both higher Charlson Index values and a conservative management were independently associated with a higher mortality.

Prognosis of Patients With Severe Aortic Stenosis After the Decision to Perform an Intervention

INTRODUCTION AND OBJECTIVES Current therapeutic options for severe aortic stenosis (AS) include transcatheter aortic valve implantation (TAVI) and surgical aortic valve replacement (SAVR). Our aim was to describe the prognosis of patients with severe AS after the decision to perform an intervention, to study the variables influencing their prognosis, and to describe the determinants of waiting time > 2 months. METHODS Subanalysis of the IDEAS (Influence of the Severe Aortic Stenosis Diagnosis) registry in patients indicated for TAVI or SAVR. RESULTS Of 726 patients with severe AS diagnosed in January 2014, the decision to perform an intervention was made in 300, who were included in the present study. The mean age was 74.0 ± 9.7 years. A total of 258 (86.0%) underwent an intervention: 59 TAVI and 199 SAVR. At the end of the year, 42 patients (14.0%) with an indication for an intervention did not receive it, either because they remained on the waiting list (34 patients) or died while waiting for the procedure (8 patients). Of the patients who died while on the waiting list, half did so in the first 100 days. The mean waiting time was 2.9 ± 1.6 for TAVI and 3.5 ± 0.2 months for SAVR (P = .03). The independent predictors of mortality were male sex (HR, 2.6; 95%CI, 1.1-6.0), moderate-severe mitral regurgitation (HR, 2.6; 95%CI, 1.5-4.5), reduced mobility (HR, 4.6; 95%CI, 1.7-12.6), and nonintervention (HR, 2.3; 95%CI, 1.02-5.03). CONCLUSIONS Patients with severe aortic stenosis awaiting therapeutic procedures have a high mortality risk. Some clinical indicators predict a worse prognosis and suggest the need for early intervention.

Bleeding risk assessment and comorbidities in elderly patients with acute coronary syndromes.

We have read with great interest the article by Faustino et al. recently published in this journal. The incidence of acute coronary syndromes (ACS) in the elderly is increasing, and information on clinical management and risk stratification in these patients is scarce, since they are clearly under-represented in clinical trials. Faustino et al. reported that the CRUSADE bleeding risk score had a low ability (area under the receiver operating characteristic curve [AUC] 0.51) to predict major in-hospital bleeding in a series of 544 octogenarian patients with non-ST-elevation ACS, suggesting the need for new tools to predict major bleeding in this clinical scenario. In contrast, the authors found the GRACE score had good performance for predicting in-hospital mortality. In our opinion, the most important limitation of this interesting work is the use of a different bleeding definition from that which formed the basis for the performance of the CRUSADE score. In the original paper by Subherwal et al., the CRUSADE bleeding criteria were fulfilled in almost 10% of patients, of whom 44% had a hematocrit drop >12% and 68% were transfused with a baseline hematocrit higher than 28%. Faustino et al. used the GUSTO bleeding criteria, which are significantly different from the CRUSADE criteria. On the other hand, only 16 patients in Faustino et al.’s series had major in-hospital bleeding, which may weaken their findings. However, we agree with the authors that these data may suggest the CRUSADE score has poor predictive ability in the elderly. We recently studied a population of 2036 consecutive ACS patients, assessing the predictive ability of the main available bleeding risk scores (CRUSADE, Mehran and ACTION) in patients aged 75 years or older (n=369, 18.1%)

Clinical treatment and prognosis in patients with acute coronary syndrome and anemia.

We read with great interest the thought-provoking study reported by Raposeiras Roubı́n et al. about the impact of severe anemia on the treatment and outcome of patients with non-STelevation acute coronary syndrome. We share the authors concern for these patients, given that they represent a numerous group that is almost always systematically excluded from the clinical trials that form the basis of the clinical guidelines. It is well known that, despite the recommendations made by the guidelines, the highest-risk patients with non-ST-elevation acute coronary syndrome usually receive the most conservative treatment according to the different registries available. One of the most widespread interpretations of this apparent contradiction is that these patients have a higher hemorrhagic risk and more comorbidities. Thus, anemia is usually associated with older age and more comorbidities and a more conservative treatment, both in terms of the antithrombotic regimen and the use of an invasive strategy. The data published by Raposeiras Roubı́n et al confirm this hypothesis, given the greater age and incidence of the main comorbidities in this subgroup of patients with hemoglobin < 10 g/dL, as well as the lower percentage of patients who undergo invasive strategy compared with those with mild anemia or no anemia. A noteworthy finding of this series is that there were no differences in the prevalence of the main comorbidities according to whether the patients underwent an invasive strategy within the group with hemoglobin < 10 g/dL. In our opinion, it is likely that factors such as the presence of active hemorrhage, the risk of hemorrhage, or the physician’s subjective perception of frailty may have been significantly different according to whether the patient underwent catheterization. Thus, the systematic quantification of factors such as frailty, prior functional status, and comborbidities could help reduce the uncertainty regarding risk stratification in acute coronary syndrome in real-world patients. On the other hand, there is little information published on the specific causes of death in patients with acute coronary syndrome and anemia. In younger patients, recent data suggest a greater contribution of noncardiac causes. In our opinion, this is a fundamental topic in the analysis of the prognostic impact of an invasive strategy in non-ST-elevation acute coronary syndrome in patients with anemia, given that cardiac deaths could in theory be reduced with a more aggressive cardiac treatment although some noncardiac deaths (renal failure, bleeding complications) may increase, as noted by the authors. Irrespective of these considerations, we feel compelled to congratulate the authors on their brilliant study. We believe there is a particular need to encourage rigorous, high-quality research into the treatment and prognosis of patients with comorbidities, who are often excluded from clinical trials. Studies such as that by Raposeiras Roubı́n et al are without doubt a stimulus for such studies.

Prognostic Impact of Primary Percutaneous Coronary Intervention in the Very Elderly STEMI Patient: Insights From the Codi Infart Registry

The incidence of acute myocardial infarction (AMI) in elderly individuals is high. This population has higher rates of complications and represents a greater burden on health resources. Moreover, elderly individuals are underrepresented in clinical trials. A few randomized trials on reperfusion in elderly patients with AMI have included patients aged around 80 years, but extrapolation of these results to the general elderly population could be limited. Information on the impact of reperfusion on very elderly patients in everyday clinical practice is also limited. The objective of this study was to analyze the association between primary percutaneous coronary intervention and midterm mortality in very elderly patients with AMI and ST-elevation AMI (STEMI) attended in clinical practice after implementation of a regional program (June, 2009, Codi Infart). Two cohorts were studied. The first was a retrospective cohort of consecutive patients aged 80 years or more with STEMI who were not reperfused or who underwent fibrinolysis in tertiary hospitals (between 2005 and 2009). The second was a prospective cohort of consecutive patients aged 80 years or older with STEMI who underwent primary percutaneous intervention between 2010 and 2011, drawn from