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Frailty and acute coronary syndrome: A structured literature review.

ABSTRACT: The health burden of acute coronary syndrome (ACS) and frailty is high, but the impact of frailty on ACS treatment and outcomes is uncertain. In this structured literature review, we investigated the relationship between frailty, ACS treatment and outcomes. Between 2000 and 2016, we identified only a small number of primary research studies investigating frailty and ACS care ( n = 10). Frailty was independently associated with increased mortality following ACS (adjusted all-cause mortality hazard ratios for patients with frailty ranged from 1.54 to 5.39). Older people with frailty were significantly less likely to receive guideline-indicated ACS care, including percutaneous coronary intervention (PCI) (rates ranged from 6.7% to 43.7% vs. from 30.4% to 69.5%). Available data for PCI indicated a gap between treatment recommended by international guidelines and clinical practice. Further research is warranted in order to investigate methods for identifying frailty in the acute setting and opportunities for improving care among older people with frailty presenting with ACS.

SUBMITTER: Bebb O

PROVIDER: S-EPMC7614831 | biostudies-literature | 2018 Mar

REPOSITORIES: biostudies-literature

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Frailty and acute coronary syndrome: A structured literature review.

Bebb Owen O Smith Fraser Gd FG Clegg Andrew A Hall Marlous M Gale Chris P CP

European heart journal. Acute cardiovascular care 20170320 2

The health burden of acute coronary syndrome (ACS) and frailty is high, but the impact of frailty on ACS treatment and outcomes is uncertain. In this structured literature review, we investigated the relationship between frailty, ACS treatment and outcomes. Between 2000 and 2016, we identified only a small number of primary research studies investigating frailty and ACS care ( n = 10). Frailty was independently associated with increased mortality following ACS (adjusted all-cause mortality hazar ...[more]

PMID: 29064267

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Project description:IntroductionAdult-onset Still's disease is a rare systemic autoinflammatory disease. We present a case of a young man with a constellation of symptoms and myopericarditis as a complication of this disease.CaseA 36-year-old Hispanic man with no significant past medical history developed a quotidian fever pattern following an upper respiratory tract infection. He initially presented with chest pain concerning for myocardial infarction and underwent cardiac catheterization, which revealed non-obstructive coronary artery disease. He was found to have myopericarditis, significant neutrophilic leukocytosis, and hyperferritinemia. He improved on high-dose corticosteroids but developed steroid-induced psychosis, and 4 months from symptom onset, he finally received tocilizumab, which eventually induced remission without adverse reactions.DiscussionAdult-onset Still's disease should be considered in a patient with fevers of undetermined origin. Due to its multisystemic involvement, adult-onset Still's disease is often a diagnosis arrived at after an extensive cardiac, hematologic, malignant, and infectious workup. Imaging, laboratory testing, and bone marrow biopsy were necessary to rule out alternative etiologies of this patient's presentation. Steroids are the mainstay of treatment because they are easily affordable, although the high risk of adverse effects makes them less desirable. Interleukin-1 inhibitors (anakinra or canakinumab) and interleukin-6 inhibitor tocilizumab are the steroid-sparing biologic agents of choice but are cost-prohibitive.ConclusionAdult-onset Still's disease should be considered in the differential diagnoses of fever of undetermined origin. Early identification and initiation of treatment are critical to faster recovery and prevention of progression to severe complications. Steroids remain the standard first-line therapy and should be followed by disease-modifying steroid sparing drugs. The social determinants of health may preclude their timely initiation and should alert providers of proactive ways to avoid further delays.

Project description:BackgroundReduced estimated glomerular filtration rate (eGFR) is associated with lower use of invasive management and increased mortality after acute coronary syndrome (ACS). The reasons for this are unclear.MethodsA retrospective clinical cohort study was performed using data from the English National Institute for Health Research Health Informatics Collaborative (2010-2017). Multivariable logistic regression was used to investigate whether eGFR<90 mL/min/1.73 m2 was associated with conservative ACS management and test whether (a) differences in care could be related to frailty and (b) associations between eGFR and mortality could be related to variation in revascularisation rates.ResultsAmong 10 205 people with ACS, an eGFR of <60 mL/min/1.73m2 was found in 25%. Strong inverse linear associations were found between worsening eGFR category and receipt of invasive management, on a relative and absolute scale. People with an eGFR <30 mL compared with ≥90 mL/min/1.73 m2 were half as likely to receive coronary angiography (OR 0.50, 95% CI 0.40 to 0.64) after non-ST-elevation (NSTE)-ACS and one-third as likely after STEMI (OR 0.30, 95% CI 0.19 to 0.46), resulting in 15 and 17 per 100 fewer procedures, respectively. Following multivariable adjustment, the ORs for receipt of angiography following NSTE-ACS were 1.05 (95% CI 0.88 to 1.27), 0.98 (95% CI 0.77 to 1.26), 0.76 (95% CI 0.57 to 1.01) and 0.58 (95% CI 0.44 to 0.77) in eGFR categories 60-89, 45-59, 30-44 and <30, respectively. After STEMI, the respective ORs were 1.20 (95% CI 0.84 to 1.71), 0.77 (95% CI 0.47 to 1.24), 0.33 (95% CI 0.20 to 0.56) and 0.28 (95% CI 0.16 to 0.48) (p<0.001 for linear trends). ORs were unchanged following adjustment for frailty. A positive association between the worse eGFR category and 30-day mortality was found (test for trend p<0.001), which was unaffected by adjustment for frailty.ConclusionsIn people with ACS, lower eGFR was associated with reduced receipt of invasive coronary management and increased mortality. Adjustment for frailty failed to change these observations. Further research is required to explain these disparities and determine whether treatment variation reflects optimal care for people with low eGFR.Trial registration numberNCT03507309.

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Frailty and acute coronary syndrome: A structured literature review.

Publications

Frailty and acute coronary syndrome: A structured literature review.

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