Frailty first: Rethinking invasive strategies for elderly patients with non-ST-elevation myocardial infarction

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.

Key Words: Percutaneous coronary intervention; Cardiac catheterization; Frailty; Non-ST-elevation myocardial infarction

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.

TO THE EDITOR

The management of non-ST-elevation myocardial infarction (NSTEMI) in elderly patients is increasingly common, yet clinical decision-making remains complex in the presence of frailty. In their recent study, Popat et al[1] provide important insights into how frailty modifies the risks and benefits of percutaneous coronary intervention (PCI) in patients aged ≥ 75 years. Frailty was assessed using the hospital frailty risk score, an ICD-10-based claims tool, and patients were categorized as having low, intermediate, or high frailty[1]. Using the United States National Inpatient Sample (2021-2022), the authors analyzed more than 450000 NSTEMI admissions and reported several clinically relevant findings.

First, PCI was associated with a reduction in in-hospital mortality across all frailty strata, supporting its potential benefit even in very elderly patients. Second, the magnitude of survival benefit progressively declined with increasing frailty, underscoring the importance of physiologic reserve. Third, frailty was strongly associated with excess procedural complications, longer hospital stays, and higher healthcare costs, highlighting the resource-intensive nature of invasive care in this population.

These findings have important clinical and policy implications. Frailty should not be regarded as an absolute contraindication to PCI; rather, it should function as a modifier in patient-centered decision-making. Importantly, frailty assessment could be practically integrated into existing NSTEMI risk stratification. Widely used ischemic risk scores, such as global registry of acute coronary events and thrombolysis in myocardial infarction, do not account for biological vulnerability and functional decline[2]. Simple, validated bedside tools, including the clinical frailty scale or the FRAIL questionnaire, could be incorporated as complementary modifiers to aid in choosing invasive vs conservative management strategies[3].

Routine frailty assessment, however, faces several real-world challenges. Barriers include time constraints in acute coronary care, limited clinician familiarity with frailty instruments, and the absence of frailty metrics in established acute coronary syndrome pathways[4].

Beyond risk stratification, attention should also focus on strategies to improve outcomes in frail patients undergoing invasive management. Prehabilitation programs combining tailored exercise, nutritional optimization, and careful medication review may reduce complications[5]. Moreover, multidisciplinary care models may help translate frailty recognition into clinical benefit.

Limitations of this retrospective analysis must be acknowledged. The use of administrative data and an ICD-10-based frailty index, the lack of angiographic detail and long-term outcomes, and potential residual confounding limit causal inference. Nonetheless, by capturing real-world practice patterns in a large and under-represented population, the study by Popat et al[1] makes a compelling case for frailty-informed cardiology.

CONCLUSION

In summary, frailty assessment should evolve into a routine component of NSTEMI management. Future prospective studies should clarify how frailty can be formally integrated into risk prediction models, identify which frail patients derive the greatest net benefit from invasive strategies, and determine whether targeted interventions such as prehabilitation can mitigate risk. Until then, clinicians should heed the central message of this study: PCI can be lifesaving in frail older patients with NSTEMI, but its benefits vary and its risks are higher, making systematic frailty assessment essential to individualized care.