Early coronary angiography and survival in older adults with nstemi: a frailty-adjusted analysis
P Darko, B Otchere, P Berchie, E Hama, E Vince, X Salazar, B Demoss, A Krishnamoorthy, R Singh, R Lougani, K Bauza, S Damle, E Molina, C MartiAbstract
Background
Older adults with non–ST-segment elevation myocardial infarction (NSTEMI) are a heterogeneous population in whom the benefits of early invasive management remain uncertain. Frailty, a multidimensional marker of biological vulnerability, is common in this group but poorly incorporated into routine clinical decision-making. Concerns about procedural risk may lead to delayed or deferred coronary angiography in frail patients despite potential ischemic benefit. Whether early coronary angiography improves survival across the frailty spectrum in older adults with NSTEMI is unclear.
Purpose
To evaluate the association between early coronary angiography and in-hospital mortality among older adults with NSTEMI, accounting for frailty burden and assessing effect modification by frailty severity.
Methods
We conducted a retrospective cohort study using the MIMIC-IV database, including adults aged ≥75 years hospitalized with NSTEMI. Frailty was quantified using a validated deficit-accumulation frailty index derived from ICD-based diagnoses and early laboratory abnormalities. Early coronary angiography was defined by procedure codes occurring within a ≤24-hour proxy window based on chart date. Multivariable logistic regression estimated adjusted odds ratios for in-hospital mortality, adjusting for frailty index, age, sex, race/ethnicity, insurance status, and admission laboratory values. Effect modification by frailty was assessed using interaction models. Robustness was evaluated using inverse probability of treatment weighting (IPTW) with stabilized and trimmed weights.
Results
Among 3,202 older NSTEMI admissions, 812 (25.4%) underwent early coronary angiography and 2,390 (74.6%) did not. Patients receiving early angiography were less frail, indicating marked treatment selection by frailty. After multivariable adjustment, early coronary angiography was independently associated with lower odds of in-hospital mortality. Frailty index remained a strong, independent predictor of mortality, with progressively higher risk across increasing frailty burden. Interaction analyses showed lower predicted mortality with early angiography across the frailty spectrum, with greatest absolute benefit at lower-to-moderate frailty and attenuation at extreme frailty. IPTW analyses demonstrated consistent results with adequate propensity score overlap and stable weights.
Conclusion
In older adults hospitalized with NSTEMI, early coronary angiography is associated with lower in-hospital mortality after accounting for frailty and clinical confounders. Although frailer patients are less likely to receive early invasive management, the survival benefit persists across a broad range of frailty severity. These findings highlight frailty as a key determinant of both treatment selection and outcomes and support a biology-informed approach to invasive decision-making beyond chronological age alone.For image description, please refer to the figure legend and surrounding text.For image description, please refer to the figure legend and surrounding text.