Angiographic and Procedural Characteristics in Frail Older Patients with Non-ST Elevation Acute Coronary Syndrome.

Background: Angiographic and procedural characteristics stratified by frailty status are not known in older patients with non-ST elevation acute coronary syndrome (NSTEACS). We evaluated angiographic and procedural characteristics in older adults with NSTEACS by frailty category, as well as associations of baseline and residual SYNTAX scores with long-term outcomes. Methods: In this study, 271 NSTEACS patients aged ≥75 years underwent coronary angiography. Frailty was assessed using the Fried criteria. Angiographic analysis was performed using QAngio® XA Medis in a core laboratory. Major adverse cardiovascular events (MACE) consisted of all-cause mortality, MI, stroke or transient ischaemic attack, repeat unplanned revascularisation and significant bleeding. Results: Mean (±SD) patient age was 80.5 ± 4.9 years. Compared with robust patients, patients with frailty had more severe culprit lesion calcification (OR 5.40; 95% CI [1.75-16.8]; p=0.03). In addition, patients with frailty had a smaller mean improvement in culprit lesion stenosis after percutaneous coronary intervention (50.6%; 95% CI [45.7-55.6]) than robust patients (58.6%; 95% CI [53.5-63.7]; p=0.042). There was no association between frailty phenotype and completeness of revascularisation (OR 0.83; 95% CI [0.36-1.93]; p=0.67). A high baseline SYNTAX score (≥33) was associated with adjusted (age and sex) 5-year MACE (HR 1.40; 95% CI [1.08-1.81]; p=0.01), as was a high residual SYNTAX score (≥8; adjusted HR 1.22; 95% CI [1.00-1.49]; p=0.047). Conclusion: Frail adults presenting with NSTEACS have more severe culprit lesion calcification. Frail adults were just as likely as robust patients to receive complete revascularisation. Baseline and residual SYNTAX score were associated with MACE at 5 years.

Sex differences in long-term outcomes in older adults undergoing invasive treatment for non-ST elevation acute coronary syndrome: An ICON-1 sub-study.

Background: Cardiovascular disease is the leading cause of mortality for females globally, yet females are underrepresented in studies of acute coronary syndrome (ACS). Studies investigating sex-related differences in clinical outcomes of patients with non-ST elevation ACS (NSTEACS) have reported divergent results, and it is unknown whether long-term outcomes for older people with NSTEACS differ between males and females. Methods: The multi-centre prospective cohort study, ICON-1, consisted of patients aged ≥75 years undergoing coronary angiography following NSTEACS. The primary composite endpoint was all-cause mortality, myocardial infarction, unplanned revascularisation, stroke, and bleeding. We report outcomes at five-years by sex. Results: Of 264 patients, 102 (38.6%) females and 162 (61.4%) males completed the five-year follow-up and were included in the analytic cohort. At admission, females were older than males (82 ± 4.3 years vs 80.0 ± 4.1 years p = 0.018). Co-morbidity profile and GRACE score were similar between the groups. There were no differences in the provision of invasive or pharmacological treatments between sexes. At five-years, there were no association between sex and the primary outcome. Conclusion: In older adults with invasive treatment of NSTEACS, provision of guideline-indicated care and long-term clinical outcomes were similar between males and females.

Five-year clinical outcomes in patients with frailty aged ≥75 years with non-ST elevation acute coronary syndrome undergoing invasive management.

Aim: Frailty is associated with adverse outcomes in older patients with acute coronary syndrome (ACS). The impact of frailty on long-term clinical outcomes following invasive management of non-ST elevation ACS (NSTEACS) is unknown. Methods and results: The multi-centre Improve Clinical Outcomes in high-risk patieNts with ACS 1 (ICON-1) prospective cohort study consisted of patients aged >75 years undergoing coronary angiography following NSTEACS. Patients were categorized by frailty assessed by Canadian Study of Health and Ageing Clinical Frailty Scale (CFS) and Fried criteria. The primary composite endpoint was all-cause mortality, unplanned revascularization, myocardial infarction, stroke, and bleeding. Of 263 patients, 33 (12.5%) were frail, 152 (57.8%) were pre-frail, and 78 (29.7%) were robust according to CFS. By Fried criteria, 70 patients (26.6%, mean age 82.1 years) were frail, 147 (55.9%, mean age 81.3 years) were pre-frail, and 46 (17.5%, mean age 79.9 years) were robust. The composite endpoint was more common at 5 years among patients with frailty according to CFS (frail: 22, 66.7%; pre-frail: 81, 53.3%; robust: 27, 34.6%, P = 0.003), with a similar trend when using Fried criteria (frail: 39, 55.7%; pre-frail: 72, 49.0%; robust: 16, 34.8%, P = 0.085). Frailty measured with both CFS and Fried criteria was associated with the primary endpoint [age and sex-adjusted hazard ratio (HR) compared with robust groups. CFS: 2.22, 95% confidence interval (CI) 1.23-4.02, P = 0.008; Fried: HR 1.81, 95% CI 1.00-3.27, P = 0.048]. Conclusion: In older patients who underwent angiography following NSTEACS, frailty is associated with an increased risk of the primary composite endpoint at 5 years. Registration: Clinicaltrials.gov NCT01933581.

Is the contemporary care of the older persons with acute coronary syndrome evidence-based?

Globally, ischaemic heart disease is the leading cause of death, with a higher mortality burden amongst older adults. Although advancing age is associated with a higher risk of adverse outcomes following acute coronary syndrome (ACS), older patients are less likely to receive evidence-based medications and coronary angiography. Guideline recommendations for managing ACS are often based on studies that exclude older patients, and more contemporary trials have been underpowered and produced inconsistent findings. There is also limited evidence for how frailty and comorbidity should influence management decisions. This review focuses on the current evidence base for the medical and percutaneous management of ACS in older patients and highlights the distinct need to enrol older patients with ACS into well-powered, large-scale randomized trials.

Impact of multimorbidity on long-term outcomes in older adults with non-ST elevation acute coronary syndrome in the North East of England: a multi-centre cohort study of patients undergoing invasive care.

OBJECTIVES: Older adults have a higher degree of multimorbidity, which may adversely affect longer term outcomes from non-ST elevation acute coronary syndrome (NSTE-ACS). We investigated the impact of multimorbidity on cardiovascular outcomes 5 years after invasive management of NSTE-ACS. DESIGN: Prospective cohort study. SETTING: Multicentre study conducted in the north of England. PARTICIPANTS: 298 patients aged ≥75 years with NSTE-ACS and referred for coronary angiography, with 264 (88.0%) completing 5-year follow-up. MAIN OUTCOME MEASURES: Multimorbidity was evaluated at baseline with the Charlson comorbidity index (CCI). The primary composite outcome was all-cause mortality, myocardial infarction, stroke, urgent repeat revascularisation or significant bleeding. RESULTS: Mean age was 80.9 (±6.1) years. The cohort median CCI score was 5 (IQR 4-7). The primary composite outcome occurred in 48.1% at 5 years, at which time 31.0% of the cohort had died. Compared with those with few comorbidities (CCI score 3-5), a higher CCI score (≥6) was positively associated with the primary composite outcome (adjusted HR (aHR) 1.64 (95% CI 1.14 to 2.35), p=0.008 adjusted for age and sex), driven by an increased risk of death (aHR 2.20 (1.38 to 3.49), p=0.001). For each additional CCI comorbidity, on average, there was a 20% increased risk of the primary composite endpoint at 5 years (aHR 1.20 (1.09 to 1.33), p<0.001). CONCLUSIONS: In older adults with NSTE-ACS referred for coronary angiography, the presence of multimorbidity is associated with an increased risk of long-term adverse cardiovascular events, driven by a higher risk of all-cause mortality. TRIAL REGISTRATION NUMBER: NCT01933581; ClinicalTrials.gov.

Frailty and quality of life after invasive management for non-ST elevation acute coronary syndrome.

OBJECTIVE: Older patients presenting with non-ST elevation acute coronary syndrome (NSTEACS) require holistic assessment. We carried out a longitudinal cohort study to investigate health-related quality of life (HRQoL) of older, frail adults with NSTEACS undergoing coronary angiography. METHODS: 217 consecutive patients aged ≥65 years (mean age 80.9±4.0 years, 60.8% male) with NSTEACS referred for coronary angiography were recruited from two tertiary cardiac centres between November 2012 and December 2015. Frailty was assessed with the Fried Frailty Index; a score of 0 was characterised as robust, 1-2 prefrail and ≥3 frail. The Short Form Survey 36 (SF-36), an HRQoL tool consisting of eight domains spanning physical and mental health, was performed at baseline and 1 year. RESULTS: 186 patients (85.7%) had invasive revascularisation. At baseline, 52 (23.9%) patients were frail and 121 (55.8%) were prefrail, with most SF-36 domains falling below the norm-population mean. Patients with frailty had lower mean scores in all physical SF-36 domains (p≤0.05) compared with those without frailty. Robust patients had temporal improvement in two domains (role physical +5.80 (95% CI 1.31 to 10.3) and role emotional +6.46 (95% CI 1.02 to 11.9)) versus patients with frailty and prefrailty, who had a collective improvement in a greater number of physical and psychological domains at 1 year (2 domains vs 11 domains), notably role physical (prefrail +6.53 (95% CI 3.85 to 9.20) and frail +10.4 (95% CI 6.7814.1)). CONCLUSIONS: Frail older adults with NSTEACS have poor HRQoL. One year following invasive management, there are modest improvements in HRQoL, most marked in frail and prefrail patients, who received a proportionally larger benefit than robust patients. TRIAL REGISTRATION NUMBER: NCT01933581.

Role of coronary angiogram before transcatheter aortic valve implantation.

BACKGROUND: Coexistent coronary artery disease is commonly seen in patients undergoing transcatheter aortic valve implantation (TAVI). Previous studies showed that pre-TAVI coronary revascularisation was not associated with improved outcomes, challenging the clinical value of routine coronary angiogram (CA). AIM: To assess whether a selective approach to perform pre-TAVI CA is safe and feasible. METHODS: This was a retrospective non-randomised single-centre analysis of consecutive patients undergoing TAVI. A selective approach for performing CA tailored to patient clinical need was developed. Clinical outcomes were compared based on whether patients underwent CA. The primary endpoint was a composite of all-cause mortality, myocardial infraction, repeat CA, and re-admission with heart failure. RESULTS: Of 348 patients (average age 81 ± 7 and 57% male) were included with a median follow up of 19 (9-31) mo. One hundred and fifty-four (44%) patients, underwent CA before TAVI procedure. Patients who underwent CA were more likely to have previous myocardial infarction (MI) and previous percutaneous revascularisation. The primary endpoint was comparable between the two group (22.6% vs 22.2%; hazard ratio 1.05, 95%CI: 0.67-1.64, P = 0.82). Patients who had CA were less likely to be readmitted with heart failure (P = 0.022), but more likely to have repeat CA (P = 0.002) and MI (P = 0.007). In those who underwent CA, the presence of flow limiting lesions did not affect the incidence of primary endpoint, or its components, except for increased rate of repeat CA. CONCLUSION: Selective CA is a feasible and safe approach. The clinical value of routine CA should be challenged in future randomised trials.

Does Transcatheter Aortic Valve Implantation for Aortic Stenosis Impact on Cognitive Function?

Aortic stenosis (AS) is the most common valvular heart disease among elderly patients in developed countries. Surgical valve replacement is indicated for severe AS to relieve the obstructed outflow tract. Transcatheter aortic valve implantation (TAVI) has emerged as an alternative for patients with severe AS, particularly in those with high surgical risk. TAVI is a less invasive approach with favorable survival outcomes in high-risk patients compared with open surgery. Despite the remarkable success of TAVI, there is a growing concern on the incidence of postprocedural cognitive impairment. This review aims to evaluate the incidence of cognitive impairment following TAVI and to identify the potential contributing factors.

The association between vitamin D status and clinical events in high-risk older patients with non-ST elevation acute coronary syndrome undergoing invasive management.

There is a higher incidence of vitamin D deficiency in older adults. This may play a plausible mechanistic role in the occurrence of increased adverse events after non-ST elevation acute coronary syndrome (NSTEACS). This study investigated whether total vitamin D levels at the time of presentation predicted adverse outcomes in older adults undergoing invasive management of NSTEACS. Of the 629 patients screened, 300 high-risk older adults with NSTEACS managed by an invasive strategy were recruited. Serum total 25-hydroxyvitamin D was measured at index presentation. The primary outcome was defined as 1-year composite of all-cause mortality, acute coronary syndrome (ACS), unplanned repeat revascularisation, significant bleeding or stroke. Mean age was 80.5±4.8 years (61.9% male). Median vitamin D level was 29.5nmol/L [interquartile range IQR 16.0-53.0 nmol/L] and was split equally by the median for analysis forming two groups: high (median vitamin D 53.0 nmol/L [IQR 40.0-75.0]) and low (16.0 nmol/L [11.0-23.0]). The primary outcome occurred in 76 patients (25.9%); 32 (21.9%) in the low group and 44 (29.9%) in the high group, p = 0.12. Multivariable analyses showed no significant difference in the primary composite outcome at 1 year between the low and high group of baseline serum vitamin D (Hazard Ratio 1.20 [95% Confidence Interval 0.72-2.0], p = 0.48). Serum total vitamin D, measured at the time of angiography, was not associated with adverse outcomes at one year in this high-risk older cohort of patients with NSTEACS undergoing invasive management.

Cognitive Decline in Older Patients With Non- ST Elevation Acute Coronary Syndrome.

Background Dementia is a growing health burden of an aging population. This study aims to evaluate the prevalence of cognitive impairment and the predictors of cognitive decline at 1 year in older patients with non-ST-elevation acute coronary syndrome undergoing invasive care. Methods and Results Older patients with non-ST-elevation acute coronary syndrome were recruited into the ICON1 study. Cognition was evaluated using Montreal Cognitive Assessment. The composite major adverse cardiovascular events comprised death, myocardial infarction, unplanned revascularization, stroke, and significant bleeding at 1 year. Of 298 patients, 271 had cognitive assessment at baseline, and 211 (78%) had follow-up Montreal Cognitive Assessment at 1 year. Mean age was 80.5±4.8 years. There was a high prevalence (n=130, 48.0%) of undiagnosed cognitive impairment (Montreal Cognitive Assessment score <26) at baseline. Cognitive impairment patients were more likely to reach major adverse cardiovascular events by Kaplan-Meier analysis ( P=0.047). Seventy-four patients (35.1%) experienced cognitive decline (Montreal Cognitive Assessment score drop by ≥2 points) at 1 year. Recurrent myocardial infarction was independently associated with cognitive decline at 1 year (odds ratio 3.19, 95% confidence interval 1.18-8.63, P=0.02) after adjustment for age and sex. Conclusions In older patients undergoing invasive management of non-ST-elevation acute coronary syndrome, there is a high prevalence of undiagnosed cognitive impairment at baseline. Recurrent myocardial infarction is independently associated with cognitive decline at 1 year. Clinical Trial Registration URL: http://www.clinicaltrials.gov . Unique identifier: NCT01933581.

One-year clinical outcomes in older patients with non-ST elevation acute coronary syndrome undergoing coronary angiography: An analysis of the ICON1 study.

AIMS: The aim of this prospective, observational study was to identify predictors of adverse outcome at one year, following invasive care of older patients with non-ST-elevation acute coronary syndrome (NSTEACS) according to frailty status. METHODS: Older patients (aged ≥ 75 years), presenting with NSTEACS, undergoing invasive coronary angiography with a view to revascularisation, underwent assessment of frailty, cognition, functional status and quality of life. Participants were categorised as robust, pre-frail or frail using the Fried criteria. The primary outcome comprised a composite of all-cause mortality, myocardial infarction, stroke, unplanned revascularisation and major bleeding, at one year. Cox proportional hazards regression was used to derive a multivariate risk score. RESULTS: Overall, the composite endpoint was observed in 81 participants (29%). There was a significant difference in the occurrence of the primary outcome in the 3 frailty groups (robust 18.0%, pre-frail 27.5% and frail 39%; p = 0.03; hazard ratio (HR) for frail vs. robust: 2.79, 95% Confidence Interval [CI] 1.28-6.08). Fried frailty classification, age (categorised as ≥85 years), raised Killip class, systolic blood pressure on admission, history of peripheral vascular disease (PVD), problems dressing self and implantation of a bare metal stent were identified as predictors of adverse events at one year, with a C-statistic of 0.77 (95% CI 0.71-0.83). A point-based clinical risk score (FRAIL-HEART) was defined, which had a C-statistic of 0.70 (95% CI 0.63-0.77) and significantly outperformed the GRACE 2 score. CONCLUSION: Frailty is associated with adverse clinical outcomes, following invasive management of older patients with NSTEACS. The derived risk models may enable improved risk stratification in practice.

Widening interest, widening participation: factors influencing school students' aspirations to study medicine.

BACKGROUND: Under-representation of some socio-economic groups in medicine is rooted in under-representation of those groups in applications to medical school. This study aimed to explore what may deter school-age children from applying to study medicine. METHODS: Workshops were undertaken with school students aged 16-17 years ('Year 12', n = 122 across three workshops) and 13-14 years ('Year 9', n = 295 across three workshops). Workshops used a variety of methods to identify and discuss participants' perceptions of medicine, medical school and the application process. Year 12 workshops focused on applications and medical school, while Year 9 took a broader approach reflecting their relative distance from applying. Subsequent workshops were informed by the findings of earlier ones. RESULTS: The main finding was that potential applicants had limited knowledge about medicine and medical school in several areas. Older students would benefit from accessible information about medical degrees and application processes, access to work experience opportunities and personal contact with medical students and junior doctors, particularly those from a similar background. Younger students demonstrated a lack of awareness of the breadth of medical careers and a limited understanding of what medicine encompasses. Many Year 9 students were attracted by elements of practice which they did not associate with medicine, such as 'talking to people with mental health problems'. An exercise addressing this elicited an increase in their interest in medicine. These issues were identified by participants as being more marked for those without knowledgeable support at home or school. It was apparent that school teachers may not be equipped to fill these knowledge gaps. CONCLUSION: Gaps in knowledge and support may reflect the importance of 'social capital' in facilitating access to medical school. Medical schools could act as hubs to introduce students to resources which are essential for widening participation. Outreach and support to schools may ensure that fundamental knowledge gaps are equitably addressed for all prospective applicants. More generally, a focus on medicine which under-emphasises aspects of medical practice involving communication may deter some students and have longer term impact on recruitment to careers including general practice and psychiatry.