Frailty in acute coronary syndrome: From risk stratification to clinical decision-making

Abstract

Frailty is a common condition among older adults presenting with acute coronary syndrome and is recognized as a significant determinant of both short- and long-term outcomes. This literature review summarizes the concept of frailty and the assessment tools most relevant in acute care. We synthesize evidence linking frailty to mortality, prolonged hospitalization, and procedural complications, and highlight how heterogeneity among different frailty assessment tools has limited comparisons between studies and the incorporation of guidelines. For healthcare professionals, we propose a pragmatic approach: Rapid screening at first contact using a simple, validated tool; targeted multi-domain assessment for those with a positive result; and clear integration of frailty status into shared decision-making regarding interventional strategies, discharge planning, and transitional care. We identify key gaps, most notably the lack of randomized trials stratified by frailty, limited implementation research on frailty-guided care pathways, and the need to standardize metrics for cardiac testing and registries. Integrating frailty assessment into routine acute coronary syndrome care holds promise for improved individualized risk prediction and more patient-centered management, but will require coordinated research, clearer reporting standards, and feasible clinical workflows.

Key Words: Frailty; Acute coronary syndrome; Acute care; Assessment; Older adults

Core Tip: Frailty is increasingly recognized as a crucial determinant of outcomes in patients with acute coronary syndrome. This mini review highlights the most widely used frailty assessment tools, their prognostic value, and their practical application in emergency and inpatient cardiology settings. By summarizing current evidence and proposing a pragmatic pathway for integrating frailty into decision-making, the review underscores how simple bedside screening can guide individualized care, improve risk prediction, and support cardio-geriatric collaboration in managing older adults with acute coronary syndrome.

INTRODUCTION

One of the most significant demographic changes of the 21^st century, which has already posed challenges to public health, is the rapid aging of the global population[1-3]. Frailty is a complex clinical syndrome common among older adults, characterized by decreased physiological reserves and a diminished ability of the body to adapt and respond to stressors. Since frailty is associated with adverse health outcomes - such as falls, disability, prolonged hospitalization, and ultimately death - its assessment is crucial for identifying individuals who may benefit from targeted interventions and improved management strategies[4-6].

Epidemiological data vary significantly depending on the assessment tool used. Among elderly individuals living in the community, the prevalence of frailty ranges from 4% to 59%, while the rates of prefrailty can reach up to 53%[6,7]. Frailty is particularly common in older patients with established cardiovascular disease, occurring at much higher rates than in the general population[8,9]. Recent data reveal that frailty is present in 30% of patients with coronary artery disease, 80% of patients with heart failure, and 74% of patients with severe aortic stenosis[10]. This relationship appears to be bidirectional, as frail individuals are more likely to have cardiovascular disease, and those with cardiovascular disease are more likely to experience some functional impairment[11].

Frailty has been recognized as a significant risk factor for severe cardiovascular events, as demonstrated by the cardiovascular health study, which revealed strong associations between frailty and functional decline, increased falls, and higher mortality. Specifically, in patients undergoing percutaneous coronary intervention (PCI), incorporating frailty assessment into conventional risk evaluation improved mortality prediction, particularly for patients with acute coronary syndrome (ACS)[12]. Despite growing awareness of frailty’s importance, the optimal method for its assessment in ACS patients has not yet been established. Furthermore, most studies are either observational and utilize various assessment tools or focus on patients who are not in the acute phase[13-16]. Consequently, there is uncertainty regarding the most appropriate assessment tool, the timing and patient selection for frailty evaluation, and the strategies for managing frailty in the hospital setting[17].

The purpose of this literature review is to: (1) Examine the significance of frailty assessment in patients with ACS; (2) Evaluate the various tools used in clinical practice for assessing frailty; and (3) Analyze the relationship between frailty and patient prognosis. The review aims to highlight the implications of these findings for managing cardiac cases and intensive care strategies within the hospital setting.

FRAILTY IN ACS

Frailty is a term commonly used to describe a multifactorial syndrome characterized by a loss of biological reserves, resulting in increased vulnerability. Although it has been extensively studied in recent years, its definition remains unclear and imprecise. Several definitions have been proposed to explain this complex phenomenon[18,19].

Frailty has been described as a loss of function that leads to increased vulnerability in response to stress and health-related events. Alternatively, it is characterized as a medical syndrome with multiple causes and risk factors, defined by a loss of strength and diminished physiological functions that increase a person’s vulnerability to losing independence, ultimately leading to disability and death[20,21].

McDonagh et al[22] defines frailty as a multidimensional syndrome characterized by increased vulnerability to acute stressors such as hospitalization, falls, and infections. At the frailty consensus conference, experts agreed on a more comprehensive definition, which includes an evaluation of parameters such as physical performance, gait speed, mobility, nutritional status, and mental and cognitive function[22,23].

The growing importance of recognizing frailty is demonstrated by the development of a robust evidence base, which includes two key models: The phenotypic model and the cumulative deficits model. The phenotypic model focuses on identifying individuals with evident weakness, for whom timely intervention may delay or prevent disability. In contrast, the cumulative deficits model pertains to individuals already experiencing comorbidities and other conditions that contribute to an overall health deficit[11,24,25].

Regardless of the definition of frailty, the fundamental assumption remains the same: Individuals with frailty are more vulnerable to clinical complications during concurrent illness or other stressful situations[26]. ACS represents one such stressful situation, which particularly exacerbates the condition of frail individuals. Over 40% of patients admitted with ACS are older than 75 years[27]. The combination of ACS and frailty may lead to serious complications, poorer prognoses, prolonged hospital stays, and ultimately adverse clinical outcomes[28-31]. A recent meta-analysis highlighted the vicious cycle between these two conditions. Specifically, in 4458 patients with ACS, frailty was associated with increased mortality during hospitalization [relative risk = 2.89; 95% confidence interval (CI): 2.49-3.34] and longer hospital stays [standardized mean difference = 2.01; 95%CI: 1.48-2.46), with frail ACS patients staying an average of 3.5 days longer in hospital than non-frail ACS patients. Moreover, frailty increased the risk of adverse events such as major bleeding (relative risk = 2.03; 95%CI: 1.51-2.73)[32].

This interaction is further exacerbated by chronic inflammation, which develops in frail individuals due to an imbalance between pro-inflammatory and anti-inflammatory pathways. The increased production of pro-inflammatory cytokines, such as interleukin-6, tumor necrosis factor-α, and C-reactive protein, heightens the body’s vulnerability, delays recovery, and raises the risk of infections and cardiovascular complications, thereby further burdening the clinical condition of patients with ACS[33-37].

Additionally, dysregulation of proteostasis due to overactivity of the ubiquitin proteasome system leads to excessive protein degradation, resulting in muscle atrophy and cardiovascular dysfunction. This process creates a vicious cycle of deterioration, whereby the body’s inability to maintain its biological reserves makes recovery from ACS even more challenging[38,39].

The combination of an ageing population, improved survival rates from cardiovascular disease, and increased recognition of frailty makes acute cardiovascular disease in frail individuals a priority area for care[40,41]. Despite the growing acknowledgement of the need for better care for this patient group, there remains a need for more specialized guidelines regarding the safety, effectiveness, and management of these patients.

FRAILTY ASSESSMENT

In addition to biological mechanisms, numerous factors influence an individual’s frailty, including age, reduced nutritional intake, lack of physical activity, and multimorbidity. The American Heart Association recommends considering frailty syndrome, cognitive function, and coexisting illnesses when assessing risk and selecting treatment for ACS[42].

Since frailty is a complex syndrome involving multiple deficits, its assessment requires a comprehensive approach. This assessment varies depending on the clinical setting and therapeutic objectives. Typically, a complete frailty assessment includes: (1) Questions about daily activities; (2) Questionnaires evaluating physical autonomy as well as the individual’s cognitive and emotional state; (3) Laboratory parameters; and (4) Objective measurements of physical performance[43,44].

Many tools developed to assess frailty have been created within the framework of the comprehensive geriatric assessment (CGA), which can involve more than 40 components and requires formal clinical evaluation[25,45]. The CGA records not only cumulative clinical and functional deficits and nutritional status but also social parameters. As a fully validated tool, the CGA is considered one of the best models for managing frailty (whether cognitive, nutritional, functional, or social) in a hospital setting. However, the CGA is time-consuming, and its implementation depends on the setting and available resources[46,47].

To achieve a more accurate and personalized diagnosis of frailty, various tools and scales have been developed, offering a wide range of assessment methods. Most of these tools have been validated in clinical conditions other than ACS, making them particularly useful in clinical practice. These tools range from scales focusing on physical condition and autonomy to more comprehensive methods that combine the biological, psychological, and social characteristics of the patient[48].

Table 1 provides a comparative overview of validated frailty assessment tools applied to populations with ACS. These tools vary significantly in their methodological approach, ranging from simple clinical scales such as the Clinical Frailty Scale (CFS)[20] to multidimensional questionnaires such as the Edmonton Frail Scale (EFS) and the Tilburg Frailty Indicator (TFI)[49,50], as well as objective markers derived from electronic health records [Hospital Frailty Risk Score (HFRS)] or Laboratory Frailty Index (FI-Lab)[51,52]. Each approach offers distinct advantages and limitations: Clinical scales, such as the CFS, are quick and feasible at the patient’s bedside, whereas multidimensional scales provide a more comprehensive picture at the expense of increased administration time. Conversely, electronic and laboratory-derived indicators allow for large-scale risk stratification without direct patient contact, although they depend on the completeness and quality of the available data.

Table 1 Comparative characteristics of validated frailty assessment tools in patients with acute coronary syndrome.

Tool	Type of assessment	Time required	Training requirements	Clinical advantages	Limitations
Clinical Frailty Scale[20]	9-point clinical scale	< 5 minutes, bedside	Minimal	Strong prognostic indicator of short-term and long-term mortality in ACS[54]	Subjective; requires clinical judgement
Edmonton Frail Scale[49]	Multidimensional questionnaire	Approximately 10 minutes	Moderate	Better discrimination for mortality and prolonged hospital stay in ACS; improves GRACE/EuroSCORE II[60]	Time-consuming in emergency settings
Fried Frailty Phenotype[12]	Phenotypic model (5 criteria)	10-15 minutes	Moderate (requires measurements)	Prognostic value for mortality and complications in ACS[61]	Requires equipment and patient cooperation
FRAIL scale	5-item questionnaire	< 5 minutes	Minimal	Very quick and simple, suitable for acute phases[63]	Less sensitive for mild frailty
Hospital Frailty Risk Score[51]	Administrative index - ICD-10	Automated (EHR)	Access to administrative data	Suitable for large-scale use; improves mortality prediction in ACS[64]	Less clinical detail
Laboratory Frailty Index[52]	Index based on laboratory data	Automated	Access to lab results	Objective; enhances prognostic models in ACS	Does not account for psychosocial factors
Physical performance tests (SPPB, gait speed, TUG, grip strength)[95]	Objective performance-based tests	5-10 minutes	Training in measurement techniques	Prognostic value for MACE and mortality in ACS	Requires patient’s physical participation
SHARE-FI/Frailty Index[17]	Deficit accumulation index	Automated or questionnaire	Access to data or brief training	Multidimensional; used in ACS with evidence of prognostic value	Fewer ACS-specific studies
Tilburg Frailty Indicator[50]	Multidimensional tool (physical, psychological, social)	10-15 minutes	Moderate	Covers nonphysical dimensions; evidence for prognosis in cardiac patients[69]	Not extensively validated specifically for ACS

FRAIL: Fatigue, Resistance, Ambulation, Illness and Loss of Weight Index; SPPB: Short Physical Performance Battery; TUG: Timed Up and Go Test; SHARE-FI: Survey of Health, Ageing and Retirement in Europe-Frailty Instrument; ICD-10: International Classification of Diseases, Tenth Revision; EHR: Electronic health record; ACS: Acute coronary syndrome; GRACE: Global Registry of Acute Coronary Event; EuroSCORE II: European System for Cardiac Operation Risk Evaluation II; MACE: Major adverse cardiovascular events.

Specifically, the CFS has been widely used in patients with ACS, offering a quick and straightforward assessment of functional status with strong prognostic value for both short- and long-term mortality[53-55]. Studies in ACS consistently demonstrate that higher CFS scores predict poorer outcomes. Ekerstad et al[56] found that frailty (CFS ≥ 5) in elderly patients with non-ST segment elevation myocardial infarction was independently associated with approximately 4-fold higher 1-year mortality (hazard ratio = 4.3; 95%CI: 2.1-8.7) and higher in-hospital and monthly mortality [adjusted odds ratio (OR) = 4.6, 95%CI: 2.9-7.1; OR = 4.7, 95%CI: 3.0-7.4]. In clinical practice, these findings suggest that frailty assessment provides incremental prognostic information and should be incorporated into early clinical evaluation to guide treatment intensity and discharge planning. Its simplicity and rapid application make it ideal for use in emergencies, particularly in high-risk patients undergoing primary PCI.

Although the EFS requires more time to complete, it provides a multidimensional assessment encompassing physical, cognitive, and social parameters, and has been associated not only with mortality but also with 6-month readmissions[57,58]. In prospective studies, the EFS outperformed the CFS in predicting non-cardiovascular complications, such as infections and falls within the hospital. The evidence for ACS is more limited but suggests that the EFS predicts adverse outcomes. In a cohort of elderly patients with ACS, frailty as assessed by the EFS strongly predicted mid-term all-cause mortality (frail vs non-frail hazard ratio approximately of 3.6)[59]. Graham et al[60] found that higher EFS scores were associated with significantly longer hospital stays (mean 12.7 days vs 7.0 days) and higher 1-year mortality (12.7% vs 1.6%). Thus, the EFS identifies patients with ACS who are at risk of prolonged hospital stay and death.

A tool documented under real-world conditions in the coronary disease unit is the Fried Frailty Phenotype. It serves as a strong prognostic marker for major adverse cardiovascular events and overall mortality, but its use in emergency situations is limited by the requirement for physical measurements (e.g., grip strength and walking speed)[44]. However, in more stable settings or rehabilitation units, it provides a detailed functional assessment. For example, in a cohort study, patients ≥ 65 years of age were followed for three years, and frailty (defined as meeting three or more Fried criteria) predicted significantly worse 3-year outcomes: Mortality was 28% in frail patients vs 6% (frail vs non-frail) and death/myocardial infarction 41% vs 17%[61]. Conversely, the Fatigue, Resistance, Ambulation, Illness and Loss of Weight Index (FRAIL) scale, due to its simplicity, is particularly useful in the acute phase, although it is less sensitive in identifying mild frailty. In smaller studies, it has demonstrated prognostic value for short-term mortality and length of hospital stay. Previous research found that each additional point on the FRAIL scale increased the risk of mortality and predicted long-term outcomes (death from any cause or readmission) with similar accuracy to the Global Registry of Acute Coronary Events (GRACE) score[43,62]. Nevertheless, further evidence is required regarding its sensitivity, especially in patients with multiple comorbidities.

The HFRS and FI-Lab utilize routinely available data - administrative and laboratory, respectively - facilitating large-scale implementation and seamless integration into electronic health systems[63,64]. Their primary limitation is the exclusion of psychosocial domains. In a recent study, Nguyen et al[65] reported that an HFRS ≥ 5 identified ACS patients at substantially higher risk of in-hospital adverse outcomes, including major bleeding (OR approximately of 4.1), pneumonia (OR approximately of 2.6), all-cause mortality (OR approximately of 3.1), and non-cardiac death (OR approximately of 10.7). Similarly, laboratory-based frailty indices demonstrate prognostic value. In critically ill myocardial infarction patients from the Medical Information Mart for Intensive Care IV database, a 33-item FI-Lab independently predicted both in-hospital and one-year mortality. Each 0.01 increase in FI-Lab was associated with approximately 6% higher odds of in-hospital death and 5% higher odds of one-year mortality. Risk stratification by quartiles revealed a graded relationship, with the highest quartile conferring nearly sixfold increased odds of in-hospital mortality (OR approximately of 5.8). Importantly, FI-Lab provided incremental prognostic information beyond conventional severity scores in acute myocardial infarction[66]. Both tools offer scalable, objective approaches to risk stratification in cardiovascular care, supporting more personalized management. However, their reliance on administrative or laboratory data limits psychosocial assessment, emphasizing the need for more comprehensive frailty measures in clinical practice.

The Survey of Health, Ageing and Retirement in Europe-Frailty Instrument (SHARE-FI) is based on the accumulation of deficits and provides a multidimensional assessment, whereas the TFI also encompasses non-physical dimensions and is indicated for use in cardiac patients, although its validation in ACS remains limited. SHARE-FI combines psychosocial questions with grip strength measurement and has been shown to identify high-risk ACS patients. Alonso Salinas et al[67] found that SHARE-FI-defined frail patients had significantly higher 30-day major bleeding rates (8.5% vs 0.8% in non-frail patients) and more frequent composite events, including death, myocardial infarction, and stroke. Similarly, the TFI, which assesses physical, psychological, and social frailty, has demonstrated prognostic value when combined with established risk tools. In a cohort of 196 elderly ACS patients, Wontor et al[68] reported that adding the TFI to the GRACE risk model improved prediction of 6-month mortality (area under the curve 0.737 vs 0.713), with high GRACE + TFI scores conferring nearly a seven-fold increase in the risk of death. Together, these findings suggest that incorporating psychosocial frailty measures such as SHARE-FI and TFI enhances traditional ACS risk stratification by identifying patients at greater risk of adverse outcomes and mortality.

The choice of an appropriate tool must consider the clinical objective, resource availability, and context of application. The literature suggests that tools combining physical and cognitive/psychosocial dimensions (e.g., EFS, TFI) provide a more comprehensive prediction of long-term outcomes, whereas simpler scales (CFS, FRAIL scale) excel in speed and feasibility during the acute phase. Electronic and laboratory-derived tools (FI-Labs, HFRS) offer considerable scalability and integration potential within automated protocols but lack personalization and clinical detail. Tool selection should not be arbitrary: In emergency intervention settings, the CFS or FRAIL scale may be the most suitable choice, whereas in secondary prevention or rehabilitation contexts, the EFS, Fried Frailty Phenotype, or TFI can offer deeper insights.

COMPREHENSIVE RISK STRATIFICATION

All recent data support the integration of frailty into the risk stratification of patients with ACS to personalize their treatment, both during the acute phase and throughout rehabilitation and follow-up[69,70]. For example, Wontor et al[68] demonstrated that adding the TFI to the GRACE score improved mortality prediction (area under the curve 0.737 vs 0.713; Net Reclassification Index +0.11). Alonso Salinas et al[27] also reported that frailty independently predicted short-term prognosis in elderly ACS patients. The GRACE score is the most widely used risk assessment tool for patients with ACS and as shown by multicenter clinical studies, provides high prognostic value[71-73]. However, considering the comprehensive care model increasingly adopted for these patients, as well as the evolving profile of ACS patients, assessment using the GRACE score alone is incomplete, as it lacks factors related to the patient’s physical, cognitive, and social condition. Recent studies have provided evidence on this issue; when a frailty scale was added to the assessment and combined with the GRACE score, the ability to predict short- and long-term mortality, as well as serious complications after PCI improved significantly[27,68,74].

Data on frail patients with ST-segment elevation myocardial infarction remain limited, as most randomized studies focus on very elderly individuals without systematic frailty assessment[75,76]. Nevertheless, combined analyses have shown that primary PCI is superior to thrombolysis even in patients over 75 years of age, although the long-term prognosis for this group remains worse than that for younger patients[77]. Factors such as longer ischemia times, a higher frequency of multivessel disease, increased bleeding complications, and lower rates of successful reperfusion may explain this outcome[78,79].

Frailty can provide additional prognostic information in this context; for example, slow walking speed at discharge has been associated with increased long-term mortality following primary PCI[80]. Despite the elevated risks, the rates of immediate complications are generally acceptable, suggesting that PCI should not be automatically excluded in frail patients[81,82]. When PCI is not immediately available, thrombolysis in very elderly individuals requires careful assessment of bleeding risk, and in some cases, the use of a reduced dose of thrombolytics has been considered a strategy to limit complications[83].

Although most data come from patients with ST-segment elevation myocardial infarction, the need to integrate frailty into risk assessment is equally critical for patients with non-ST-segment elevation myocardial infarction. Both groups share common challenges, such as the underrepresentation of frail individuals in randomized studies and a tendency towards undertreatment - but they differ in terms of the therapeutic framework and the extent of available data, necessitating the adaptation of risk stratification strategies for each ACS subtype[84].

In patients with non-ST-segment elevation myocardial infarction, frailty is a strong independent prognostic factor influencing both short-term and medium-term mortality, irrespective of comorbidities. Guidelines continue to recommend a routine invasive strategy; however, in practice, this approach is less frequently employed in frail patients, possibly due to the complexity of coronary lesions or concerns about increased complications[40]. Observations indicate that frail patients who undergo coronary angiography have lower rates of revascularization, which may reflect either the unsuitability of the lesion for PCI or a preference for a more conservative approach[61].

Randomized controlled trials in patients over 80 years old, such as the After Eighty trial, compared an invasive strategy with a conservative approach, demonstrating a significant short-term benefit in terms of the composite endpoint of death or major cardiovascular events[85,86]. However, this benefit is not always maintained during long-term follow-up, emphasizing the need for improved selection of suitable patients. Incorporating frailty into the initial risk assessment could help identify those most likely to benefit from an invasive approach without being exposed to disproportionate risk.

According to the European Society of Cardiology (2023) and American Heart Association/American College of Cardiology (2022) guidelines, the assessment of frailty in elderly patients and those with multiple comorbidities should precede the choice of an invasive or conservative management strategy. This approach appears to reduce not only the risk of overtreatment and complications but also delays in patients who could genuinely benefit from invasive treatment[40,42,87]. Therefore, frailty assessment is recommended to be conducted promptly upon hospital admission and, in combination with prognostic cardiology scores such as the GRACE score, used to inform decisions regarding invasive or conservative management based on the patient’s risk-benefit profile.

INTERDISCIPLINARY CARE-CARDIO-GERIATRICS

Effective management of vulnerable patients with ACS requires an approach that extends beyond conventional care. The model of geriatric cardiology integrates the management of cardiovascular diseases with a particular focus on the care of older patients, delivering individualized, holistic, and patient-centered care to this population group[88,89]. This approach is characterized by a collaborative, interdisciplinary nature, combining the expertise of cardiologists, geriatricians, general practitioners, nurses, physiotherapists, pharmacists, dietitians, and social workers to address the complex needs of elderly patients[88,90].

Given the unique characteristics of older patients with cardiovascular disease, cardio geriatrics aims to adapt healthcare systems to improve the care of this patient group. Although pilot initiatives of this kind in ACS patients remain limited, the available evidence is highly encouraging. In a real-world study, the establishment of a specialized cardio-geriatric follow-up service after hospital discharge for patients with acute heart failure was associated with a reduction in one-year mortality and hospital readmissions compared with standard care[91]. In Italy, the application of the CGA in ACS patients supported better patient selection for invasive therapy as well as targeted support for frail patients, improving functional recovery and reducing morbidity[92].

The need for initiatives that integrate individualized treatment into clinical practice is substantial. Current data suggest that this patient group is often undertreated. Large registry analyses have shown that patients with a high frailty index receive invasive treatments less frequently, despite having a higher cardiovascular risk and greater mortality at one-year follow-up[70]. Similar trends have been observed in the Italian BLITZ registry among frail older ACS patients[93].

International experience demonstrates that implementing such models on a national scale is feasible. In Denmark, a nationwide registry incorporating standardized frailty assessments has shown improved one-year survival rates and reduced complications, independent of chronological age[94]. Adopting similar frameworks in Greece - which faces a significant demographic challenge - could begin with pilot programs in large hospitals. These would include frailty assessment upon admission, decision-making regarding optimal treatment, weekly geriatrician presence in cardiology wards, nurse training in frailty evaluation and relevant interventions to enhance hospital care, and the development of discharge protocols encompassing referrals to individualized cardiac rehabilitation, nutritional support, and social care[95]. The combined recording of standard cardiological indicators alongside frailty assessment tools could form the foundation of a national registry to support both clinical practice and research.

FUTURE APPROACHES

The increasing number of elderly patients with ACS, alongside the recognition of frailty as a prognostic marker, makes its integration into both research and clinical practice imperative. Frail patients remain largely underrepresented in major clinical trials. Furthermore, existing studies that do include frail patients tend to focus primarily on heart failure or aortic valve stenosis. Consequently, including frail patients with ACS could help determine optimal therapeutic strategies during both the acute phase and follow-up.

The diversity of existing frailty assessment tools, coupled with the lack of one specifically designed for cardiology patients, presents challenges. Therefore, adopting simple, validated, and cardiology-specific frailty assessment instruments could provide a common framework for interpreting results across studies and enable the tailoring of interventions to individual patient needs.

Frailty can either worsen or develop for the first time during a severe illness, opening new avenues for research into its pathophysiology and for the development of interventions to facilitate recovery. The use or adaptation of appropriate assessment tools in younger cardiology patients may aid in the early identification of those at greater risk of complications.

CONCLUSION

Frailty is a significant prognostic factor in patients with ACS, influencing prognosis, length of hospital stays, and mortality. Early, standardized assessment, combined with cardiological risk scores, can enhance risk stratification and guide treatment decisions. Despite its importance, frail patients remain underrepresented in studies and are often undertreated. The use of validated tools, interdisciplinary care, and tailored interventions to meet their specific needs can improve outcomes and contribute to more equitable and effective cardiological care.