New York—Using medications alone to manage frail older patients who have had heart attacks might be a way to lower their risk of major bleeding, a new study suggests.

The study, published in JACC: Cardiovascular Interventions, notes that, despite frailty, many older patients routinely undergo cardiac catheterization after acute myocardial infarction (AMI), in addition to using anticoagulants.

New York University–led researchers report that frail patients older than age 65 years had a 50% greater risk of major bleeding when hospitalized during a heart attack, compared with nonfrail patients.

A key finding was the that risk was increased in frail patients who underwent cardiac catheterization, but not those who were managed with medications alone.

Despite some smaller studies that looked at aspects of the relationship between heart attack treatment and bleeding, this is the first study to gather data from the ACTION Registry–now known as the Chest Pain-MI Registry—researchers pointed out.

“Beginning in 2015, the ACTION Registry began to capture this information, allowing us to have two years’ worth of data,” explained lead study author John A. Dodson, MD, MPH, FACC, an NYU cardiologist. “By analyzing this information, we were able to confirm that there is indeed a correlation between frailty and greater risk of bleeding in this population.”

For the study, frailty was classified based on three impairment domains:
• Walking (unassisted, assisted, wheelchair/non-ambulatory)
• Cognition (normal, mildly impaired, moderately/severely impaired)
• Basic activities of daily living (bathing, eating, dressing, toileting)

Impairment in each domain was scored as 0, 1, or 2, and a summary variable consisting of three categories was then created: 0 (fit/well), 1 to 2 (vulnerable/mild frailty), and 3 to 6 (moderate-to-severe frailty). Multivariable logistic regression was used to examine the independent association between frailty and bleeding.

The study team focused on 129,330 AMI patients over age 65 years from 775 U.S. hospitals between January 2015 and December 2016. Of participants, 16.4% had any frailty, and those patients tended to be older, more often female, and less likely to undergo cardiac catheterization. 

Results indicate that major bleeding increased across categories of frailty (fit/well, 6.5%; vulnerable/mild frailty, 9.4%; moderate-to-severe frailty, 9.9%; P <.001). In fact, researchers found that, among patients who underwent catheterization, both frailty categories were independently associated with bleeding risk compared with the nonfrail group (vulnerable/mild frailty adjusted odds ratio [OR]: 1.33, 95% CI: 1.23-1.44; moderate-to-severe frailty adjusted OR: 1.40, 95% CI: 1.24-1.58).

On the other hand, for patients managed conservatively with medications, no association of frailty with bleeding was identified (vulnerable/mild frailty adjusted OR: 1.01, 95% CI: 0.86-1.19; moderate-to-severe frailty adjusted OR: 0.96, 95% CI: 0.81- 1.14).

“Frail patients had lower use of cardiac catheterization and higher risk of major bleeding (when catheterization was performed) than nonfrail patients, making attention to clinical strategies to avoid bleeding imperative in this population,” the study authors concluded.

“As the U.S. population ages, there is an increasing number of older people who are experiencing acute myocardial infarction—and often they are managing other health problems at the same time,” Dodson emphasized. “Our findings highlight that frailty is an important variable to consider when managing these patients, beyond the characteristics we traditionally use. We need to look even more closely at evidence-based clinical strategies to avoid bleeding in this population.”

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