Long-Term Prognostic Value of Cognitive Impairment on Top of Frailty in Older Adults after Acute Coronary Syndrome.

Frailty is a marker of poor prognosis in older adults after acute coronary syndrome. We investigated whether cognitive impairment provides additional prognostic information. The study population consisted of a prospective cohort of 342 older (>65 years) adult survivors after acute coronary syndrome. Frailty (Fried score) and cognitive function (Pfeiffer's Short Portable Mental Status Questionnaire-SPMSQ) were assessed at discharge. The endpoints were mortality or acute myocardial infarction at 8.7-year median follow-up. Patient distribution according to SPMSQ results was: no cognitive impairment (SPMSQ = 0 errors; n = 248, 73%), mild impairment (SPMSQ = 1-2 errors; n = 52, 15%), and moderate to severe impairment (SPMSQ ≥3 errors; n = 42, 12%). A total of 245 (72%) patients died or had an acute myocardial infarction, and 216 (63%) patients died. After adjustment for clinical data, comorbidities, and Fried score, the SPMSQ added prognostic value for death or myocardial infarction (per number of errors; HR = 1.11, 95%, CI 1.04-1.19, p = 0.002) and death (HR = 1.11, 95% 1.03-1.20, p = 0.007). An SPMSQ with ≥3 errors identified the highest risk subgroup. Geriatric conditions (SPSMQ and Fried score) explained 19% and 43% of the overall chi-square of the models for predicting death or myocardial infarction and death, respectively. Geriatric assessment after acute coronary syndrome should include both frailty and cognitive function. This is particularly important given that cognitive impairment without dementia can be subclinical and thus remain undetected.

Frailty Tools for Assessment of Long-term Prognosis After Acute Coronary Syndrome.

OBJECTIVE: To evaluate the 5 components of the Fried frailty phenotype (self-reported unintentional weight loss, physical activity questionnaire, gait speed, grip strength, and self-reported exhaustion) for long-term outcomes in elderly survivors of acute coronary syndrome. METHODS: A total of 342 consecutive patients (from October 1, 2010, to February 1, 2012) were included. The 5 components of the Fried score and albumin concentration, as malnutrition index, were assessed before hospital discharge. Patients were followed up until April 2020 (median follow-up, 8.7 years). The end point was postdischarge all-cause mortality. RESULTS: Mean ± SD age was 77±7 years and mean ± SD Fried score was 2.0±1.1 points. A total of 216 (63%) patients died. After adjusting for clinical covariates, the Fried phenotype was associated with mortality (per points, hazard ratio [HR], 1.35; 95% CI, 1.17 to 1.57; P<.001). Among Fried components, physical activity (HR, 2.21; 95% CI, 1.34 to 3.65; P=.002) and gait speed (HR, 1.77; 95% CI, 1.29 to 2.43; P<.001) were the deficits independendtly associated with mortality. Albumin level provided further prognostic information (per increase in g/dL; HR, 0.63, 95% CI, 0.45 to 0.88; P=.007). The model adding the components of the Fried score and albumin level to the clinical model showed the highest risk reclassification (integrated discrimination improvement, 0.040; 95% CI, 0.018 to 0.075; P=.001; continuous net reclassification improvement, 0.291; 95% CI, 0.132 to 0.397; P=.001) in comparison with the model using clinical covariates alone. CONCLUSION: Frailty assessment using the Fried phenotype has prognostic value for long-term mortality in elderly survivors of acute coronary syndrome. Physical activity and gait speed are the predictive components of the Fried score. Albumin level provides incremental prognostic information.

[An invasive strategy in non-ST-segment elevation acute coronary syndromes. From large trials to the real world]. / Estrategia invasiva en el síndrome coronario agudo sin elevación del segmento ST. De los grandes estudios al mundo real.

INTRODUCTION AND OBJECTIVES: We report the impact on prognosis of an invasive strategy used at our center for non-ST-segment elevation acute coronary syndrome. PATIENTS AND METHOD: We analyzed 504 consecutive patients with typical chest pain, electrocardiographic changes or increased troponin I serum values, who were divided into 2 cohorts: a) conservative group, 272 patients admitted between October 2001 and September 2002 and managed with a conservative strategy, and b) invasive group, 232 patients admitted between October 2002 and September 2003 for whom an invasive strategy was recommended. We recorded major events (death or reinfarction) and minor events (readmission or need for postdischarge revascularization) within a 12-week follow-up period. RESULTS: In the invasive group in-hospital angioplasty (21% vs 35%, P<.0001) and in-hospital revascularization (33% vs 48%, P=.001) increased. There were no significant differences between the conservative and the invasive group regarding major events (17% vs 15%). The invasive group was associated with a reduction in minor events (17% vs 9%, P=.01). The incidence of any event was reduced (28% vs 20%, P=.04). In the multivariate analysis for the whole group (n=504) the invasive strategy significantly reduced minor events (hazard ratio 0.5 [0.3-0.8], P=.008) and any event (hazard ratio 0.5 [0.3-0.8], P=.005), but not major events (hazard ratio 0.6 [0.4-1.1], P=.09). CONCLUSIONS: The results observed in recent randomized clinical trials regarding the use of an invasive strategy were confirmed in the real world. In the short term, the benefits seem to be confined to a reduction in minor events, i.e., fewer readmissions and less need for postdischarge revascularization.

Estrategia invasiva en el síndrome coronario agudo sin elevación del segmento ST. De los grandes estudios al mundo real / An Invasive Strategy in Non-ST-Segment Elevation Acute Coronary Syndromes. From Large Trials to the Real World

Introducción y objetivos. Presentamos el impacto pronóstico de una estrategia invasiva (EI) en el síndrome coronario agudo sin elevación del segmento ST en nuestra institución. Pacientes y método. Se ha estudiado a 504 pacientes consecutivos con dolor torácico típico, cambios electrocardiográficos y elevación de la troponina I divididos en 2 cohortes: a) grupo conservador, 272 pacientes ingresa- dos entre octubre de 2001 y septiembre de 2002, manejados con una estrategia conservadora (EC); b) grupo invasivo, 232 pacientes ingresados entre octubre de 2002 y septiembre de 2003 y en los que se recomendó una EI. Se recogieron los eventos mayores (defunción o reinfarto) y menores (reingreso o necesidad de revascularización postalta) durante 12 semanas. Resultados. En el grupo invasivo se incrementó la angioplastia prealta (el 21 frente al 35%; p < 0,0001) y la revascularización prealta (el 33 frente al 48%; p = 0,001). No hubo diferencias entre los grupos conservador e invasivo en relación con los eventos mayores (el 17 frente al 15%). El grupo invasivo se relacionó con menos eventos menores (el 17 frente al 9%; p = 0,01). La incidencia de cualquier evento se redujo (un 28 frente a un 20%; p = 0,04). En el análisis multivariado global (n = 504), el manejo invasivo fue un predictor independiente de menos eventos menores (hazard ratio [HR] = 0,5; intervalo de confianza [IC] del 95%, 0,3-0,8; p = 0,008) y de cualquier evento (HR = 0,5; IC del 95%, 0,3-0,8; p = 0,005), pero no de menos eventos mayores (HR = 0,6; IC del 95%, 0,4-1,1; p = 0,09). Conclusiones. Los resultados de los estudios aleatorizados recientes respecto al uso de una EI se confirman en el mundo real. En una perspectiva a corto plazo los beneficios se centran especialmente en una reducción de eventos menores: menos reingresos y menor necesidad de revascularización postalta (AU)

Introduction and objectives. We report the impact on prognosis of an invasive strategy used at our center for non-ST-segment elevation acute coronary syndrome. Patients and method. We analyzed 504 consecutive patients with typical chest pain, electrocardiographic changes or increased troponin I serum values, who were divided into 2 cohorts: a) conservative group, 272 patients admitted between October 2001 and September 2002 and managed with a conservative strategy, and b) invasive group, 232 patients admitted between October 2002 and September 2003 for whom an invasive strategy was recommended. We recorded major events (death or reinfarction) and minor events (readmission or need for post- discharge revascularization) within a 12-week follow-up period. Results. In the invasive group in-hospital angioplasty (21% vs 35%, P<.0001) and in-hospital revascularization (33% vs 48%, P=.001) increased. There were no significant differences between the conservative and the invasive group regarding major events (17% vs 15%). The invasive group was associated with a reduction in minor events (17% vs 9%, P=.01). The incidence of any event was reduced (28% vs 20%, P=.04). In the multivariate analysis for the whole group (n=504) the invasive strategy significantly reduced minor events (hazard ratio 0.5 [0.3- 0.8], P=.008) and any event (hazard ratio 0.5 [0.3-0.8], P=.005), but not major events (hazard ratio 0.6 [0.4-1.1], P=.09). Conclusions. The results observed in recent randomized clinical trials regarding the use of an invasive strategy were confirmed in the real world. In the short term, the benefits seem to be confined to a reduction in minor events, i.e., fewer readmissions and less need for postdischarge revascularization (AU)

[Emergency room risk stratification of patients with chest pain without ST segment elevation]. / Estratificación del riesgo de pacientes con dolor torácico sin elevación del segmento ST en la puerta de urgencias.

OBJECTIVES: To investigate the prognostic factors in patients who come to the emergency room with chest pain but without ST segment elevation. PATIENTS AND METHOD: 743 consecutive patients were evaluated by recording clinical history, electrocardiogram and troponin I determination, and early (<24 h) exercise testing was done for the low-risk subgroup of patients (n=203). All patients were followed during 3 months for major events (acute myocardial infarction or death). RESULTS: Major events occurred in 71 patients (9.6%). Multivariate analysis (C statistic=0.79; 95% CI 0.73-0.84; p=0.0001) identified the following predictors: age > or =72 years (OR=1.7; 95% CI, 1.0-2.9; p=0.05), insulin-dependent diabetes mellitus (OR=2.9; 95% CI, 1.5-5.4; p=0.001), previous ischemic heart disease (OR=1.9; 95% CI, 1.1-3.2; p=0.02), ST depression (OR=2.1; 95% CI, 1.2-3.8; p=0.01) and troponin I elevation (OR=2.9; 95% CI, 1.5-5.3; p=0.001). These five predictors were used to construct a risk score based on their odds ratios, which allowed event rate stratification by quartiles of the score: 0-2 points (1.6% events), 3-4 points (8.1% events), 5-7 points (11.9% events) and > or =8 points (26.2% events); p=0.0001. No patient with negative findings in the early exercise testing had major events. CONCLUSIONS: In patients with chest pain, the combination of clinical, electrocardiographic and biochemical data available on admission to the emergency service allows rapid prognostic stratification. Early exercise testing is advisable for the final stratification of low risk patients.

Estratificación del riesgo de pacientes con dolor torácico sin elevación del segmento ST en la puerta de urgencias / Emergency room risk stratification of patients with chest pain without ST segment elevation

Objetivos. Investigar en la puerta de urgencias los factores pronósticos de pacientes que acuden por dolor torácico sin elevación del segmento ST. Pacientes y método. Se evaluó a 743 pacientes consecutivos mediante la historia clínica, el electrocardiograma, la determinación de troponina I y la ergometría precoz (< 24 h) en el subgrupo de bajo riesgo (n = 203).Todos los pacientes fueron seguidos durante 3 meses, y se recogieron los eventos mayores (infarto agudo de miocardio o muerte). Resultados. En 71 pacientes (9,6 por ciento) ocurrieron eventos mayores. En el análisis multivariable (estadístico C = 0,79; IC del 95 por ciento, 0,73-0,84; p = 0,0001) se identificaron los siguientes predictores: edad 72 años (OR = 1,7; IC del 95 por ciento, 1,0-2,9; p = 0,05), diabetes insulinodependiente (OR = 2,9; IC del 95 por ciento, 1,5-5,4; p = 0,001), cardiopatía isquémica previa (OR = 1,9; IC del 95 por ciento, 1,1-3,2; p = 0,02), descenso del segmento ST (OR = 2,1; IC del 95 por ciento,1,23,8; p = 0,01) y elevación de la troponina I (OR = 2,9; IC del 95 por ciento, 1,5-5,3; p = 0,001). Se creó una puntuación de riesgo basada en las OR de estos 5 predictores que permitió la estratificación de la población por cuartiles de esta puntuación: 0-2 puntos, 1,6 por ciento eventos; 3-4 puntos, 8,1 por ciento eventos; 5-7 puntos, 11,9 por ciento eventos; 8 puntos, 26,2 por ciento eventos; p = 0,0001. Ningún paciente con ergometría precoz negativa presentó eventos. Conclusiones. En los pacientes con dolor torácico, el conjunto de los datos clínicos, electrocardiográficos y bioquímicos disponibles en la puerta de urgencias permite establecer una rápida estratificación pronóstica. La ergometría precoz es útil para la estratificación final en los pacientes de bajo riesgo (AU)