Hanna Ratcovich

Aims: In the SENIOR-RITA trial, among older adults with non-ST-elevation myocardial infarction (NSTEMI), an invasive strategy did not reduce the composite outcome of cardiovascular death or non-fatal myocardial infarction compared with a conservative strategy over a median follow-up of 4.1 years. Objectives: To describe the angiographic characteristics of patients randomized to the invasive arm. Methods and results: SENIOR-RITA was a prospective, multicentre, randomized controlled trial recruiting NSTEMI patients aged ≥75 years. From November 2016 to March 2023, 1518 patients from 48 UK sites were randomized 1:1 to an invasive or conservative strategy. Procedural data were collected, and angiographic data were analysed using quantitative coronary angiography at the Newcastle University angiographic core laboratory using QAngio® XA Medis. Of 680 patients undergoing angiography, quantitative coronary angiography analysis was performed in 667 participants. Obstructive coronary artery disease was found in 76.8%, and 13% had prior coronary surgical revascularization. A total of 1173 lesions were identified. Most lesions (29.5%) were classified as type B2 according to the ACC/AHA classification. Lesions in patients not receiving percutaneous coronary intervention (PCI) were angiographically more complex than those treated with PCI, with a higher prevalence of type C lesions, bifurcation, ostial lesions, and the presence of collaterals. Overall, 330 patients (49.5%) underwent PCI, which was successful in 96.5% with minimal complications. Conclusion: The SENIOR-RITA angiography sub-study is the largest subgroup analysis to date in older NSTEMI adults, providing important insights into the angiographic characteristics and emphasizing the importance of a holistic, patient-centred care for older adults.

Background Frailty has been suggested as a valuable marker for predicting outcomes in older patients with cardiovascular disease. However, whether the association between frailty and adverse outcomes is similar in patients with chronic coronary syndrome (CCS) and acute coronary syndrome (ACS) remains unclear. Methods Patients ≥70 years old referred for coronary angiography (CAG) due to CCS or ACS were included and followed for 12 months. Frailty was assessed using the Clinical Frailty Scale (CFS). Patients were grouped according to their CFS into frail/vulnerable (CFS≥4) and robust (CFS=1-3). Study endpoints included all-cause mortality and new hospital admissions for bleeding, myocardial infarction, unplanned revascularisation or stroke. Results 678 patients aged ≥70 years with available CFS underwent CAG due to CCS (n=223) or ACS (n=455) and completed 12-month follow-up. The prevalence of frailty/vulnerability was higher in patients referred with CCS compared to those with ACS (CCS:43.0% vs. ACS:32.2%, p=0.009). Frail/vulnerable patients referred with CCS were younger (CCS: 76.6(±4.7) years vs. ACS: 79.6(±5.7) years, p<0.001) and less frequently treated with percutaneous coronary intervention (CCS:40.6% vs. ACS:54.6%, p=0.043). Cumulative all-cause mortality was higher in frail/vulnerable patients referred with ACS but not in those referred with CCS, compared to robust patients (log-rank p<0.001). Conclusion Among patients ≥70 years old referred for CAG 30-40% are frail/vulnerable. Frailty/vulnerability was associated with higher all-cause mortality in patients referred for CAG due to ACS, but not in those referred due to CCS. This difference in outcome may reflect variations in clinical presentation as well as potential referral bias.

Introduction: Elderly patients with acute coronary syndrome (ACS) have a higher risk of adverse cardiovascular events and may be frail but are underrepresented in clinical trials. Previous studies have proposed that frailty assessment is a better tool than chronological age, in assessing older patients’ biological age, and may exceed conventional risk scores in predicting the prognosis. Therefore, we wanted to investigate the prevalence and impact on 12-month outcomes of frailty in patients ≥70 years with ACS referred for coronary angiography (CAG). Methods: Patients ≥70 years with ACS referred for CAG underwent frailty scoring with the clinical frailty scale (CFS). Patients were divided into three groups depending on their CFS: robust (1–3), vulnerable (4), and frail (5–9) and followed for 12 months. Results: Of 455 patients, 69 (15%) patients were frail, 79 (17%) were vulnerable, and 307 (68%) were robust. Frail patients were older (frail: 80.9 ± 5.7 years, vulnerable: 78.5 ± 5.5 years, and robust: 76.6 ± 4.9 years, p < 0.001) and less often treated with percutaneous coronary intervention (frail: 56.5%, vulnerable: 53.2%, and robust: 68.6%, p = 0.014). 12-month mortality was higher among frail patients (frail: 24.6%, vulnerable: 21.8%, and robust: 6.2%, p < 0.001). Frailty was associated with a higher mortality after adjustment for age, sex, comorbidities, the Global Registry of Acute Coronary Events (GRACE) score, and revascularisation (HR 2.67, 95% CI 1.30–5.50, p = 0.008). There was no difference between GRACE and CFS in predicting 12-month mortality (p = 0.893). Conclusions: Fifteen percent of patients ≥70 years old with ACS referred for CAG are frail. Frail patients have significantly higher 12-month mortality. GRACE and CFS are similar in predicting 12-month mortality.

Funding Acknowledgements: Type of funding sources: Public hospital(s). Main funding source(s): Rigshospitalet Research Foundation Background: The number of older patients is increasing world-wide. Older patients have a higher risk of complications related to acute coronary syndrome (ACS) treatment and are more often frail. Yet, they are often missing in clinical trials, which leads to a knowledge gap in current guidelines when treating older ACS patients. Frailty scoring may be a better tool than conventional risk scores to assess prognosis. Previous studies have proposed that a patient’s biological age instead of chronological age could be used to better guide the treatment strategy in older ACS patients. Potentially frailty scoring can be used to decide a patient’s biological age. Purpose: We wanted to investigate the prevalence of frailty in a consecutive population of ACS patients ≥70 years referred to invasive angiography at a tertiary centre. Furthermore, we wanted to investigate whether frail patients had a worse 12-month outcome compared to non-frail patients. Methods: From September 2020 to September 2021 all patients ≥70 years referred to our institution with ACS were, when logistically possible, undergoing bedside frailty scoring using the clinical frailty scale (CFS). The CFS scoring was performed at the time of admission by nurses at the department. Patients were divided into three frailty groups depending on their CFS score: Robust (1-3), Vulnerable (4) and Frail (5-9). Patients were followed for 12 months. Results: During the study period, 691 patients ≥70 years old with ACS were admitted. Of the 451 (65%) patients who had a frailty assessment, 70 (16%) patients were frail, 77 (17%) were vulnerable and 304 (67%) were robust. Frail and vulnerable patients were older (frail: 80.9 (5.6) years, vulnerable: 78.5 (5.7) years and robust: 76.7 (4.8) years, p<0.001), had more comorbidities, defined as a higher Charlson index score (frail: 4.5 [4.0-5.0], vulnerable: 4.0 [4.0-6.0] and robust: 4.0 [3.0-4.0], p<0.001) and longer hospitalisation (frail: 5 [3-9.2] days, vulnerable: 8 [3.5-14.0] days and robust: 5 [3-7] days, p=0.021). Furthermore, frail and vulnerable patients less frequently underwent revascularisation during their first admission (frail: 58.9%, vulnerable: 65.1% and robust: 77.9%, p<0.001). In 12-month follow-up, frail and vulnerable patients had a higher cumulated incidence of all-cause mortality compared to robust patients (p<0.001), figure 1. Frail patients had more than four times the risk of 12-month all-cause mortality compared to robust patients (HR 4.16 (2.12-8.15), p<0.001). The association remained significant after adjustment for age and comorbidities (HR 2.71 (1.30-5.64), p=0.008), as well as for GRACE score (HR 2.98 (1.50-5.90), p=0.002), table 1. Conclusion: In patients ≥70 years old with ACS and referred to invasive angiography, frailty according to the CFS score had a prevalence of 16%. Frail and vulnerable patients had more than four times the risk of all-cause mortality in 12-month follow-up.

In high-income countries, ischaemic heart disease is the leading cause of death in women and men, accounting for more than 20% of deaths in both sexes. However, women are less likely to receive guideline-recommended percutaneous coronary intervention (PCI) than men. Women undergoing PCI have poorer unadjusted outcomes because they are older and have greater comorbidity than men, but uncertainty remains whether sex affects outcome after these differences in clinical characteristics are considered. In this paper, we review recent published evidence comparing outcomes between men and women undergoing PCI. We focus on the sex differences in PCI outcomes in different scenarios: acute coronary syndromes, stable angina and complex lesions, including the approach of left main coronary artery. We also review how gender is considered in recent guidelines and offer a common clinical scenario to illustrate the contemporary management strategies an interventional cardiologist should consider when performing PCI on a female patient.

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.

Background The ability of coronary CT angiography (cCTA) to rule out significant coronary artery disease (CAD) in older patients with non-ST segment elevation acute coronary syndromes (NSTEACS) is unclear since valid cCTA analysis may be limited by extensive coronary artery calcification. In addition, the effect of very early invasive coronary angiography (ICA) with possible revascularisation is debated. Methods This is a posthoc analysis of patients ≥75 years included in the Very Early vs Standard Care Invasive Examination and Treatment of Patients with Non-ST-Segment Elevation Acute Coronary Syndrome Trial. cCTA was performed prior to the ICA. The diagnostic accuracy of cCTA was investigated. Presence of a coronary artery stenosis ≥50% by subsequent ICA was used as reference. Patients were randomised to a very early (within 12 hours of diagnosis) or a standard ICA (within 48–72 hours of diagnosis). The primary composite endpoint was 5-year all-cause mortality, non-fatal recurrent myocardial infarction or hospital admission for refractory myocardial ischaemia or heart failure. Results Of 452 (21%) patients ≥75 years, 161 (35.6%) underwent cCTA. 19% of cCTAs excluded significant CAD. The negative predictive value (NPV) of cCTA was 94% (95% CI 79 to 99) and the sensitivity 98% (95% CI 94 to 100). No significant differences in the frequency of primary endpoints were seen in patients randomised to very early ICA (at 5-year follow-up, n=100 (46.9%) vs 122 (51.0%), log-rank p=0.357). Conclusion In patients ≥75 years with NSTEACS, cCTA before ICA showed a high NPV. A very early ICA <12 hours of diagnosis did not significantly improve long-term clinical outcomes.

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), pConclusions 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.