Frailty and invasive management in elderly patients with myocardial infarction. A report from SWEDEHEART registry

Background

The optimal management of elderly patients with non-ST-elevation myocardial infarction (NSTEMI) remains uncertain, particularly among those with frailty.

Purpose

We aimed to evaluate the association between an invasive strategy and 1-year outcomes in patients aged ≥70 years, and whether frailty modifies the treatment effect.

Methods

We included 15,537 patients aged ≥70 years with NSTEMI from 2017 to 2021; 11,743 (75.6%) underwent invasive coronary angiography, while 3,794 (24.4%) were managed conservatively. Frailty was assessed using the Clinical Frailty Scale (CFS) and categorized as 1–3 (no-frail) 4 (vulnerable), 5–6 (mildly-moderately frail), and 7–8 (severely and very severely frail) . Outcomes included 1-year major adverse cardiovascular and cerebrovascular events (MACCE), all-cause mortality, and readmission for MI or stroke. To address confounding, we performed instrumental variable (IV) analysis using a two-stage residual inclusion Cox regression with the leave-one-out centre angiography rate as the instrument, and propensity score matching (PSM).

Results

In IV-adjusted models, an invasive strategy was associated with significantly lower risk of 1-year MACCE (HR 0.53, 95% CI 0.44–0.64), mortality (HR 0.47, 95% CI 0.38–0.60), and MI (HR 0.44, 95% CI 0.30–0.64), with no significant effect on stroke (HR 0.84, 95% CI 0.41–1.72). PSM analyses confirmed these results (table 1).

The reduction in MACCE with an invasive strategy was observed in patients without or moderate frailty (CFS 1–6), but the benefit decreased as frailty increased (interaction p=0.01) and was not statistically significant in severely frail patients (CFS 7–8; HR 0.68, 95% CI 0.48–1.06) (table 2).

Conclusion

Among elderly patients with NSTEMI, an invasive strategy was associated with lower 1-year risk of cardiovascular events, including those with moderate frailty (CFS 5–6). In severely frail patients (CFS 7–8), the benefit was numerically lower but not statistically significant. These findings support considering angiography in selected older adults, with individualized risk assessment based on frailty.Outcomes