Frailty in elderly patients with non-ST elevation myocardial infarction: Balancing the risks and benefits of percutaneous coronary intervention

Abstract

Frailty has emerged as a critical determinant of clinical outcomes in cardiovascular patients undergoing invasive management. Although percutaneous coronary intervention (PCI) remains the cornerstone of therapy for acute coronary syndromes, its role in elderly and frail patients with non-ST elevation myocardial infarction (NSTEMI) continues to raise uncertainty. Recent evidence underscores the complex interplay between survival benefit, procedural risk, and healthcare utilization in this vulnerable population. In this context, Popat et al applied the hospital frailty risk score to stratify outcomes in elderly patients (≥ 75 years) undergoing PCI. Their analysis provides valuable insights into the prognostic significance of frailty assessment and its potential role in guiding individualized treatment decisions. In this letter to the editor, we reflect on these findings and discuss them in relation to current literature, practice guidelines, and future directions for managing frail elderly patients with NSTEMI.

Key Words: Frailty; Non-ST elevation myocardial infarction; Percutaneous coronary intervention; Personalised care

Core Tip: Frailty is increasingly recognized as a key determinant of outcomes in elderly patients with non-ST elevation myocardial infarction, yet its role in guiding invasive management remains debated. The recent analysis by Popat et al suggests that percutaneous coronary intervention may confer survival benefit across frailty categories, while also exposing patients to higher risks of complications, longer hospitalizations, and greater costs. These findings highlight the complexity of decision-making in this vulnerable cohort. In this letter to the editor, we reflect on these results and discuss them in the context of current literature, practice guidelines, and future directions.

TO THE EDITOR

Frailty is a multidimensional clinical condition reflecting reduced functional status and physiological reserve in response to acute stressors, extending beyond chronological age or the presence of traditional comorbidities. Its prognostic impact is increasingly recognized in acute cardiac care and after cardiovascular interventions[1]. In non-ST elevation myocardial infarction (NSTEMI), percutaneous coronary intervention (PCI) remains a cornerstone of therapy, but its role in frail elderly patients is still debated. The most recent European and American guidelines emphasize that invasive and pharmacological strategies in elderly patients with acute coronary syndromes should be individualized, balancing ischemic benefit against bleeding and procedural risks, and taking into account comorbidities, frailty, life expectancy, and quality of life[2,3].

In this context, the study by Popat et al[4] represents an important contribution. Using the 2021-2022 Nationwide Inpatient Sample (NIS) in the United States, the authors analyzed more than 450000 NSTEMI patients aged ≥ 75 years and stratified them by the hospital frailty risk score (HFRS). They reported an inverse relationship between frailty severity and PCI utilization (35% in low vs 7.5% in high frailty categories, P < 0.001). Importantly, PCI was associated with reduced in-hospital mortality across all strata, including a 57% lower odds of death in the highly frail group. However, interaction testing confirmed that the magnitude of benefit diminished progressively with increasing frailty. These findings underscore that frailty, though a marker of vulnerability, should not be considered as a contraindication for invasive management.

The observed attenuation of PCI benefit with increasing frailty is likely multifactorial. Potential contributors include a higher burden of comorbidities, impaired physiological reserve, and increased vulnerability to peri-procedural complications. These factors may collectively diminish the net survival gain and impact post-procedural recovery. Therefore, identifying such mechanisms is critical to guide personalized PCI strategies and optimize outcomes in this vulnerable subgroup.

The study has notable strengths. It provides real-world data on PCI outcomes in a very large sample of elderly NSTEMI patients, a cohort often underrepresented in randomized controlled trials. The clinical impact of frailty was assessed by stratifying patients according to a validated frailty score. Although survival benefit was attenuated with increasing frailty, the consistent reduction in mortality across all strata supports the current guideline recommendations for individualized management strategies, while discouraging a priori exclusion of frail patients from the potential benefits of PCI[2]. Importantly, the use of a contemporary, nationally representative database also strengthens the external validity of the findings and supports their applicability to routine clinical practice.

However, several aspects merit careful consideration. The HFRS, derived entirely from diagnostic codes, may overlook key frailty dimensions-including socioeconomic context, prior hospitalization details, and comorbidity severity. These limitations may lead to misclassification, suggesting and that HFRS might be more suitable for population-level research than for guiding individualized treatment decisions[5,6].

A paradox was observed in the high-frailty cohort: While PCI was still associated with survival benefit, it was also linked to higher rates of dialysis, pulmonary edema, cardiogenic shock, need for mechanical circulatory support, prolonged hospitalization, and markedly increased healthcare costs[4]. These results suggest that PCI may extend survival into more complex and resource-intensive hospitalizations, raising important questions about functional recovery, independence, and subsequent quality of life (QoL)[7,8]. However, the study does not include data on long-term QoL after PCI, a crucial endpoint in frail elderly populations that should be integrated in future research to better contextualize survival benefits and inform truly patient-centered care.

Based on the available data, attributing these adverse outcomes is still challenging. While dialysis and bleeding may plausibly represent PCI-related complications, cardiogenic shock, pulmonary edema, and need for mechanical circulation support could reflect selection bias, since frail patients with unstable clinical presentation are more likely to undergo PCI, whereas clinically stable frail patients may be managed conservatively. This selection bias is inherent to administrative datasets such as the NIS, which do not capture temporal information regarding complication onset. Accordingly, in the absence of detailed temporal data, it is challenging to determine whether these adverse outcomes were present at admission, developed later, or were related to undertreated NSTEMI in conservatively managed patients vs procedural complications in the PCI group[9].

Another important consideration relates to the lack of clinical and procedural data. The NIS does not provide information on PCI timing, angiographic characteristics, completeness of revascularization, procedural success, or post-discharge follow-up. Without these details, interpretation of the observed associations and their application to bedside decision-making remain limited. For instance, the study did not explore interactions between frailty, and clinical severity markers such as history, electrocardiogram, age, risk factors, troponin and thrombolysis in myocardial infarction scores, which are key determinants of invasive decision-making[10]. Frailty examined in isolation may therefore oversimplify risk assessment.

Overall, this study provides a solid platform for future work and the authors should be commended for their timely and important contribution. It reinforces that PCI should not be withheld solely on the basis of frailty, while exposing the complex trade-offs between survival, complications, and resource use.

Although Popat et al[4] offer principled guidance against the exclusion of frail elderly patients from PCI, the optimal strategy to balance risk and benefit in this high-risk group remains undefined. Practical and standardized decision-making algorithms are still lacking. Further research is warranted to develop validated tools that can individualize invasive management decisions based on comprehensive geriatric and cardiovascular assessments.

CONCLUSION

In this regard, prospective registries and randomized trials specifically including frail elderly patients with NSTEMI are still needed to define optimal management strategies. Such studies should incorporate frailty measures, comorbidity profiles, and acute severity indices into multiparametric risk models. Artificial intelligence tools could further integrate electronic health record data, such as functional status and socioeconomic variables, complementing the HFRS to support individualized PCI decision-making. These advancements in artificial intelligence and machine learning may ultimately refine prediction of PCI-related benefits and risks, guiding more judicious and personalized clinical care.