Benjamin Beska

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.

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.

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. 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]. In older patients who underwent angiography following NSTEACS, frailty is associated with an increased risk of the primary composite endpoint at 5 years. Clinicaltrials.gov NCT01933581 Pictures from Servier Medical Art Image Bank.

Introduction High serum parathyroid hormone (PTH) levels are associated with increased risk of cardiovascular events. Older patients have an increased risk of adverse events after non-ST elevation acute coronary syndrome (NSTEACS) and PTH may be a useful biomarker in these patients. The link between PTH, endothelial function, vascular stiffness and early outcomes after NSTEACS was evaluated. Methods Older patients (65 years old) referred for invasive management of NSTEACS were recruited into the study (n=204). Serum PTH was measured by electrochemiluminescent immunoassay and split into tertiles for analysis. Vascular stiffness was evaluated with carotid-femoral pulse wave velocity (PWV). Endothelial function was assessed by peripheral arterial tonometry, reported as natural log reactive hyperaemia index. Major Adverse Cardiovascular Events (MACE) were defined as 30 day composite of all-cause mortality, acute coronary syndrome, unplanned repeat revascularisation, significant bleeding, stroke or transient ischaemic attack. Multiple linear and logistic regressions were performed to control for age, sex, hypertension, diabetes, glomerular filtration rate and smoking status. Results Mean age was 80.7±4.0 years (64.7% male). Median PTH was 5.9 pmol/L [IQR 4.3–7.8 pmol/L] and 81 patients (39.7%) had levels above the normal range (1.1–6.4 pmol/L). There were 83 (40.7%) patients in the high (6.4 pmol/L), 62 (30.4%) in the middle (6.3–4.5 pmol/L) and 59 (28.9%) in the low tertile (4.4 pmol/L) of PTH. There was no difference in mean PWV (high 8.51±1.77 metres per second (m/s); middle 9.89±2.75 m/s; low 9.41±2.09 m/s; p=0.646) or mean natural log reactive hyperaemia index (high 0.64±0.34; middle 0.61±0.23; low 0.59±0.25; p=0.684) between PTH tertiles. There was no adjusted linear relationship between PTH and PWV (p=0.09) or natural log reactive hyperaemia index (p=0.919). MACE incidence did not vary between tertiles (high 2.4%; middle 1.6%; low 3.4%; p=0.819) and adjusting for covariates, PTH was not predictive of MACE (p=0.308). Conclusion In this high-risk older cohort, high serum PTH levels are not linked with endothelial dysfunction or vascular stiffness and do not predict early adverse events after invasive management of NSTEACS.