Milaras N, Toutouzas K, Sideris S. Frailty first: Rethinking invasive strategies for elderly patients with non-ST-elevation myocardial infarction. World J Cardiol 2026; 18(2): 114706 [DOI: 10.4330/wjc.v18.i2.114706]
Corresponding Author of This Article
Nikias Milaras, Academic Fellow, Department of Cardiology, “Hippokration” General Hospital, Vasilisis Sofias 14, Athens 11527, Greece. nikiasmilaras@gmail.com
Research Domain of This Article
Cardiac & Cardiovascular Systems
Article-Type of This Article
Letter to the Editor
Open-Access Policy of This Article
This article is an open-access article which was selected by an in-house editor and fully peer-reviewed by external reviewers. It is distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited and the use is non-commercial. See: http://creativecommons.org/licenses/by-nc/4.0/
Nikias Milaras, Skevos Sideris, Department of Cardiology, “Hippokration” General Hospital, Athens 11527, Greece
Konstantinos Toutouzas, 1st Department of Cardiology, “Hippokration” General Hospital, Athens Medical School, Athens 11527, Greece
Author contributions: Milaras N drafted the manuscript and revised it; Toutouzas K and Sideris S provided critical review, supervision, and final approval of the version to be published.
Conflict-of-interest statement: All the authors report no relevant conflicts of interest for this article.
Open Access: This article is an open-access article that was selected by an in-house editor and fully peer-reviewed by external reviewers. It is distributed in accordance with the Creative Commons Attribution NonCommercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited and the use is non-commercial. See: https://creativecommons.org/Licenses/by-nc/4.0/
Corresponding author: Nikias Milaras, Academic Fellow, Department of Cardiology, “Hippokration” General Hospital, Vasilisis Sofias 14, Athens 11527, Greece. nikiasmilaras@gmail.com
Received: September 26, 2025 Revised: November 2, 2025 Accepted: December 24, 2025 Published online: February 26, 2026 Processing time: 136 Days and 12.4 Hours
Abstract
The management of non-ST-elevation myocardial infarction (NSTEMI) in elderly patients is increasingly common, yet clinical decision-making remains challenging in the presence of frailty. In a large contemporary analysis, Popat et al examined the impact of frailty on outcomes associated with percutaneous coronary intervention (PCI) in patients aged ≥ 75 years hospitalized with NSTEMI. Frailty was assessed using the hospital frailty risk score, an ICD-10-based tool, and categorized as low, intermediate, or high. Using data from the United States National Inpatient Sample (2021-2022), more than 450000 NSTEMI admissions were analyzed. PCI was associated with reduced in-hospital mortality across all frailty categories, supporting its potential benefit even in very elderly patients. However, the magnitude of survival benefit declined progressively with increasing frailty. Higher frailty was also strongly associated with increased procedural complications, longer hospital stays, and greater healthcare costs. These findings suggest that frailty should not be viewed as an absolute contraindication to PCI, but rather as a key modifier in patient-centered decision-making. Despite limitations inherent to retrospective administrative data, this study highlights the importance of frailty-informed strategies in contemporary NSTEMI management.
Core Tip: Frailty influences outcomes in elderly patients with non-ST-elevation myocardial infarction undergoing percutaneous coronary intervention (PCI). In a large United States cohort, PCI reduced in-hospital mortality across all frailty levels, yet benefits declined and complications, length of stay, and costs rose with increasing frailty. These findings highlight that frailty should not preclude PCI but must be routinely assessed to guide individualized decision-making, risk prediction, and resource allocation in acute coronary care.
