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. 2022 Sep 28;46(1):5–12. doi: 10.1002/clc.23929

Prevalence and adverse outcomes of frailty in older patients with acute myocardial infarction after percutaneous coronary interventions: A systematic review and meta‐analysis

Qian Yu 1, Dawei Guo 2, Jianan Peng 2, Qifei Wu 1, Yonghuan Yao 1, Mei Ding 1,✉, Jiang Wang 2,✉
PMCID: PMC9849439  PMID: 36168782

Abstract

Background

The association between frailty and older patients with acute myocardial infarction (AMI) after percutaneous coronary intervention (PCI) is unclear. Therefore, we conducted a systematic review and meta‐analysis to investigate the prevalence of frailty in older patients with AMI following PCI, and determine the relationship between frailty and adverse outcomes in these patients.

Hypothesis

Older patients with AMI have a higher prevalence of frailty after PCI, and the frailty in these patients increases the risk of adverse outcomes.

Methods

A comprehensive search of the PubMed, Cochrane, Ovid (Medline), Ovid (Embase), and Web of Science databases was performed for articles published until October 2021. A meta‐analysis was performed using stata12.0 software. A random‐effects model was used when I 2 was greater than 50%; otherwise, a fixed‐effects model was used.

Results

There were a total of 274,976 older patients in the included studies. Nine studies investigated the prevalence of frailty in older patients with AMI after PCI, with an overall prevalence of 39% (95% confidence interval [CI]: 18%–60%, p < .001). Six studies included adverse outcomes of frailty in older patients with AMI after PCI, including all‐cause mortality (hazard ratio [HR] = 2.29, 95% CI: 1.65–3.16, p = .285), rehospitalization (HR = 2.53, 95% CI: 1.38–4.63), and in‐hospital major bleeding (HR = 1.93, 95% CI: 1.29–2.90, p = .825).

Conclusion

The frailty prevalence is increased in older patients with AMI after PCI, especially in ST‐segment elevation myocardial infarction (STEMI). AMI with frailty after PCI is more likely to be associated with worse clinical outcomes, such as death, bleeding, and rehospitalization.

Keywords: acute myocardial infarction, frailty, outcome, percutaneous coronary intervention, prevalence

1. INTRODUCTION

Acute myocardial infarction (AMI) is a common cardiovascular disease, usually linked to myocardial cell necrosis caused by prolonged ischemia and hypoxia of the heart. 1 In recent years, the implementation of percutaneous coronary intervention (PCI) has become more frequent, and the adverse clinical outcomes of patients with AMI have improved. 2

Frailty is a common geriatric symptom that is more common in cardiovascular disease than in the general population, 3 the clinical manifestations of which include weight loss, increased fatigue, diminished grip strength, decreased walking speed, and reduced activity. 4 In addition, frailty affects the quality of life of older population and can increase the risk of falls, hospitalization, and death. 5 Studies have shown that advancing age also increases the prevalence of frailty, with an increase of 10% over 65 years and 30% over 80 years. 6

Older adults with cardiovascular disease are three times more likely to suffer from frailty and two times as likely to die as healthy older adults. 7 Furthermore, the risk of frailty during hospitalization in patients with AMI increases due to the burden of disease and prolonged bed rest. 2 Studies have shown that frailty can predict the risk of adverse outcomes in cardiovascular disease. 7 , 8 , 9

However, the prevalence of frailty in older patients with AMI after PCI and the risk of adverse outcomes after discharge remain unclear. Therefore, we conducted a systematic review and meta‐analysis to assess the incidence of frailty and its adverse clinical effects in older patients with AMI after PCI.

2. METHODS

2.1. Search strategy and study selection

The PubMed, Cochrane, Ovid (Medline), Ovid (Embase), and Web of Science databases were searched for relevant literature published in English from the establishment of each database to October 2021. The search strategy for PubMed was as follows: frailty [MeSH terms] OR frailty * [title/abstract] AND myocardial infarction [MeSH terms] OR ((myocardial infarct* [title/abstract]) OR (heart attack* [title/abstract]) OR (attack* [title/abstract]) OR (AMI [title/abstract]). References from the included articles published in English were manually searched.

2.2. Study inclusion and exclusion criteria

We included the following studies: (1) studies in which frailty was limited to a severely frail population; (2) cross‐sectional or cohort studies which reported the prevalence of frailty in older patients with AMI after PCI; (3) studies in which the primary clinical outcomes included all‐cause, in‐hospital, and midterm deaths, and the secondary clinical outcomes were bleeding or rehospitalization, referring to intracranial, abdominal, and pelvic bleeding due to any cause; and (4) articles in English.

Two independent evaluators (Qifei Wu and Yonghuan Yao) performed literature screening to determine whether the studies met the inclusion criteria. In case of a disagreement, a third evaluator (Qian Yu) was consulted.

2.3. Data extraction

Two investigators (Qifei Wu and Yonghuan Yao) extracted the data required for this study in an Excel spreadsheet according to the purpose of the study. The data extracted included: (1) study type and country, (2) disease type, (3) sample number, age, and percentage of males, (4) frailty assessment tools, (5) frailty prevalence, (6) adverse outcomes, and (7) follow‐up time. To ensure the accuracy of data extraction, two investigators separately performed the data extraction process. Any disagreement during the data extraction was resolved by a focused discussion or by clarification with a third investigator (Qian Yu).

2.4. Evaluation of literature quality

Two investigators (Dawei Guo Jianan Peng) independently evaluated the quality of the included literature using the Newcastle–Ottawa Quality Scale. 10 This scale contains eight items in three dimensions: study population selection, comparability, and outcome measurement. The total score was 9 points. The quality scores of the studies included in this meta‐analysis were between 7 and 9 points. Four of the included studies had full scores, indicating that they had high quality.

2.5. Statistical analysis

Statistical analysis was performed using Stata 12.0. The Q‐test was used to analyze heterogeneity. Heterogeneity was considered significant at p ≤ .10. Heterogeneity was evaluated by combining this with the I 2 statistic. The larger the I 2 statistic, the more important the heterogeneity. 11 When I 2 ≤ 50%, the fixed‐effect model was used; if I 2 > 50%, the subgroup analysis and the random‐effects model were used to explore the sources of heterogeneity. For clinical outcomes, we performed a subgroup analysis to calculate the relative risk and 95% confidence interval (CI) of the association between frailty and AMI after PCI and all‐cause mortality, in‐hospital major bleeding, and rehospitalization. Sensitivity analysis was performed to verify whether the results were stable and reliable, and funnel plots were used to assess whether there was publication bias. 12 We set the funnel plot asymmetry and defined significant publication bias as a p‐value < .05 using the Begg and Egger test.

3. RESULTS

3.1. Literature search and screening results

A total of 2953 articles were obtained through database searches, comprising 402 articles from PubMed, 89 articles from Cochrane, 1238 articles from Ovid (Embase), 371 articles from Ovid (Medline), and 853 articles from Web of Science. After excluding duplicate publications and articles unrelated to the topic or abstract, 51 articles remained; 41 of which were excluded because of the study type (review, comment or letter, randomized controlled trial), or because data showing the prevalence of frailty or adverse outcomes were lacking or not associated with the primary clinical outcome. Eventually, 10 studies on the prevalence of frailty and the correlation of adverse outcomes in older patients with AMI after PCI were included (Supporting Information: Figure 1).

3.2. Basic characteristics of the included studies

Information from 10 studies including a total of 274,976 older patients with AMI after PCI was included in our study (Table 1). These 10 trials were all published in 2018–2021, with the majority (6) published in 2019, 2 , 3 , 13 , 14 , 15 , 16 , 17 , 18 , 19 , 20 and had either a cohort or cross‐sectional study design. Frailty assessment tools mainly included the frailty point scoring system (FPSS), frailty index, and clinical frailty scale. This study aimed to evaluate frailty in older patients with AMI after PCI. The primary adverse outcomes were all‐cause mortality, rehospitalization, and bleeding during follow‐up, with a maximum follow‐up of 2 years in the included studies. 17 Overall, nine studies investigated the prevalence of frailty in older patients with AMI after PCI, 3 , 13 , 14 , 15 , 16 , 17 , 18 , 19 , 20 and six involved adverse outcomes in this population. 2 , 16 , 17 , 18 , 19 , 20

Table 1.

Baseline characteristics and summary of included studies

Author year Study type Country Disease type N Age Male (%) Frailty assessment tool Prevalence (%) Outcome Follow‐up time Quality score
Damluji, 2019 3 Cross‐sectional study, cohort study United States AMI undergone PCI 140,089 ≥75 years 46.8 FI 9.9 NA NA 8
Uchmano‐wicz, 2019 13 Cross‐sectional study Poland NSTEMI undergone PCI 100 66.12 ± 10.92 61.0 TFI 80.0 NA NA 7
Dodson, 2018, 14 Cross‐sectional study United States NSTEMI undergone PCI 129,300 75.3 ± 7.7 60.2 FPSS 19.8 NA NA 9
STEMI undergone PCI 78.2
Patel, 2018, 15 Cross‐sectional study, cohort study Australia STEMI undergone PCI 1275 ≥65 years NA FI 52.6 NA NA 9
NSTEMI undergone PCI 2669 25.3
Nishihira, 2020, 2 Cohort study Japan AMI undergone PCI 96 92 (91–94) 36.0 FPSS NA In‐hospital major bleeding 375 days 7
Midterm mortality
Nguyen, 2019, 16 Cross‐sectional study, cohort study Vietnam AMI undergone PCI 163 73.5 ± 8.3 60.8 REFS 41.7 30‐day mortality 30 days 8
30‐day readmission
Yoshioka, 2019 17 Cross‐sectional study, cohort study Japan STEMI undergone PCI 273 84.6 ± 3.8 46.2 CSHA‐CFS 48.7 All‐cause mortality 2 years 9
Hermans, 2019 18 Cohort study Netherlands STEMI undergone PCI 206 79 ± 6.4 58.0 VMS score 27.7 All‐cause mortality 30 days 8
Nishihira, 2021, 19 Prospective study NA AMI undergone PCI 546 84.5 (82–88) 47.8 FPSS 27.8 All‐cause mortality 589 days 9
In‐hospital major bleeding
Calvo, 2019 20 Observational prospective study NA STEMI undergone PCI 259 82.6 ± 6 57.9 FS 19.7 In‐hospital mortality NA 7
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Abbreviations: AMI, acute myocardial infarction; CSHA‐CFS, The Canadian study of health and aging clinical frailty scale; FI, frailty index; FPSS, frailty point scoring system; FS, FRAIL scale; NA, not available; NSTEMI, non‐ST elevation myocardial infarction; PCI, percutaneous coronary intervention; REFS, Reported Edmonton Frail Scale; STEMI: ST‐elevation myocardial infarction; TFI, Tilburg Frailty Indicator; VMS score, Veiligheids Management System.

3.3. Meta‐analysis results

Figure 1 shows a meta‐analysis of the prevalence of frail older patients with AMI after PCI. Of the 10 studies included from 2018 to 2021, 9 included data on the frailty prevalence of 274,880 older patients with AMI after PCI. The overall prevalence of AMI in older patients after PCI was 39% (95% CI: 18%–60%) in the heterogeneity test (I 2 = 100%, p < .001). Our study suggested significant differences in the prevalence of AMI frailty in older patients after PCI. We performed a subgroup analysis of the type of AMI in older patients (Figure 2). Disease types are mainly divided into non‐ST‐segment elevation myocardial infarction (NSTEMI) patients underwent PCI, STEMI patients underwent PCI, and other types were uniformly classified as unclear. Among them, the studies by Dodson et al. 14 and Patel et al. 15 included older patients with STEMI and NSTEMI who underwent PCI. The prevalence of NSTEMI in patients who developed frailty following PCI was 40% (95% CI: 29%–51%) in the heterogeneity test (I 2 = 99.3%, p < .001), and that of STEMI was 45% (95% CI: 22%–69%) in the heterogeneity test (I 2 = 99.7%, p < .001).

Figure 1.

Figure 1

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Forest plot showing the prevalence of frail patients with older AMI after PCI. AMI, acute myocardial infarction; PCI, percutaneous coronary intervention.

Figure 2.

Figure 2

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Forest plot showing subgroup analysis of the type of older AMI after PCI. AMI, acute myocardial infarction; PCI, percutaneous coronary intervention.

Older patients with frailty who underwent AMI after PCI had a markedly increased risk of adverse outcomes compared with non‐frail patients with AMI after PCI (HR = 2.14, 95% CI: 1.74–2.64, p = .556, I 2 = 0.0%). A forest plot for this meta‐analysis is shown in Figure 3. We performed subgroup analysis of the types of adverse outcomes (Figure 4), including six studies comprising 1543 older adults with adverse clinical outcomes. The results showed that all‐cause mortality was significantly increased in frail older patients with AMI after PCI than in non‐frail older patients with AMI after PCI (HR = 2.29, 95% CI: 1.65–3.16, p = .285, I 2 = 19.7%). In studies published by Nishihira et al. in 2020 and 2021, 2 , 19 adverse outcomes involved in‐hospital bleeding, and the risk of bleeding was significantly increased in frail older patients with AMI after PCI than in non‐frail older patients with AMI after PCI (HR = 1.93, 95% CI: 1.29–2.90). Nguyen et al. studied all‐cause mortality and rehospitalization. 16 After PCI, frail older patients with AMI had an increased risk of rehospitalization (HR = 2.53, 95% CI: 1.38–4.63). Other subgroup analyses of the prevalence of AMI after PCI in frail older participants are shown in Supporting Information: Table 1, while other subgroup analyses of adverse outcomes in frail older participants with AMI after PCI are shown in Supporting Information: Table 2.

Figure 3.

Figure 3

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Forest plot showing risk of adverse outcomes of frail participants with older AMI after PCI. AMI, acute myocardial infarction; PCI, percutaneous coronary intervention.

Figure 4.

Figure 4

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Forest plot showing subgroup analysis of adverse outcomes of frail participants with older AMI after PCI. AMI, acute myocardial infarction; PCI, percutaneous coronary intervention.

4. DISCUSSION

This study summarizes the relationship between the prevalence of frailty and adverse outcomes in older patients with AMI after PCI. Approximately 39% of older patients with AMI develop frailty after PCI, which is more significant in older patients with STEMI undergoing PCI. Among the adverse outcomes, we found that frail older patients with AMI undergoing PCI had approximately twice the risk of all‐cause mortality, rehospitalization, and bleeding as in the non‐frail population.

PCI is the most common revascularization method for cardiovascular diseases and can significantly improve cardiovascular problems. Studies have shown that older AMI patients have an increased risk of requiring PCI and an increased prevalence of frailty. 3 The definition of frailty and assessment tools varies across studies, which consequently results in variations in the reported prevalence. 21

In this meta‐analysis, the most common frailty assessment tool was the FPSS. FPSS is a new concept about frailty based on Canadian health and aging research by Dodson et al. 14 and includes three variables: walking, cognitive function, and basic daily life. The number of items is small, the clinical application is relatively convenient, and different degrees of frailty can also be well assessed in the acute onset of AMI. The second is the frailty index, which is based on the cumulative deficit model. The frailty index takes the human body as a unified whole, and when the cumulative deficits reach a certain level, older patients with AMI will have a poor prognosis. 15 Finally, the Canadian Clinical Frailty Scale for Health and Aging (CFS), a rating score scale developed by RockWood et al. 22 A higher score on this scale indicates more severe frailty, and studies have shown that the CFS can predict the risk of STEMI death after PCI. 17

With improvements in medical technology, myocardial reperfusion therapy, PCI, thrombolytic therapy, and secondary drug prevention, the mortality rate of STEMI has decreased. 23 Sujino et al. showed that early PCI surgery in older patients may contribute to physical recovery, while PCI may have poor adverse clinical outcomes in patients with severe frailty. 24 At the same time, according to the research report of Nishihira et al., frailty is associated with a higher risk of death. 19 Qin et al. showed that patients aged ≥75 years with AMI had a higher risk of readmission 30 days after PCI, and the reasons for readmission were heart failure and infection. 25 In addition, In the acute phase, older patients may bleed during treatment. Bleeding reduces the quality of life of older patients after discharge, and patients with bleeding are more likely to experience complications outside the hospital (such as falls, disability, rehospitalization, and even death), which are considered to be related to frailty. 14 , 26 , 27 , 28

Now, in the United States, more than 1 million adults suffer from myocardial infarction each year. 29 Therefore, early intervention in patients with AMI can improve the prognosis of patients. The American Heart Association/American College of Cardiology recommends cardiac rehabilitation (CR) for secondary prevention in patients with cardiovascular disease. 30 CR refers to rehabilitation treatment that allows patients with heart disease to live autonomously through specific intervention methods. 31 In 2017, the European Society of Cardiology indicated that all patients with AMI should actively participate in cardiac rehabilitation programs, 32 consisting of appropriate exercise training, lifestyle changes, and weight and nutritional management. 31 Participation in cardiac rehabilitation programs can help patients delay the frailty process and reduce the likelihood of falls and rehospitalizations after discharge. This enhances cardiac tolerance and reduces mortality, and helps the patient regain maximum strength and a healthy life. 32 , 33 , 34

5. CONCLUSION

Overall, our analysis showed that the prevalence of frailty increases in older patients with AMI undergoing PCI, especially in patients with STEMI. Frail older patients with AMI undergoing PCI are more likely to experience worse clinical outcomes, such as death, bleeding, and rehospitalization.

6. LIMITATION

This study has several limitations. On the one hand, there was heterogeneity due to inconsistent definitions of frailty in different studies, the different frailty assessment tools used, and the different degrees of measured frailty. However, we did not perform publication bias detection because of the limited number of samples with adverse outcomes.

AUTHOR CONTRIBUTIONS

Mei Ding and Jiang Wang conceived and designed the study. Qifei Wu and Yonghuan Yao performed the literature search and the data extraction. Dawei Guo and Jianan Peng participated in the methodological quality assessment and in the statistical analysis. The protocol manuscripts were finished by Jianan Peng. All authors have checked manuscripts and approved the publication of the protocol.

CONFLICT OF INTEREST

The authors declare no conflict of interest.

Supporting information

Supplementary information.

Click here for additional data file. (71.5KB, pdf)

Supplementary information.

Click here for additional data file. (98.6KB, pdf)

Supplementary information.

Click here for additional data file. (107.4KB, pdf)

ACKNOWLEDGMENT

This study is supported by the Project Initiation of Special Fund for Graduate Innovation in 2021 (YC2021‐S798).

Yu Q, Guo D, Peng J, et al. Prevalence and adverse outcomes of frailty in older patients with acute myocardial infarction after percutaneous coronary interventions: A systematic review and meta‐analysis. Clin Cardiol. 2023;46:5‐12. 10.1002/clc.23929

Qian Yu, Dawei Guo, and Jianan Peng contributed equally to this study.

Contributor Information

Mei Ding, Email: gnyxydm@163.com.

Jiang Wang, Email: wangjiang@jgsu.edu.cn.

DATA AVAILABILITY STATEMENT

All data generated or analyzed during this study are included in this published article.

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Associated Data

This section collects any data citations, data availability statements, or supplementary materials included in this article.

Supplementary Materials

Supplementary information.

Click here for additional data file. (71.5KB, pdf)

Supplementary information.

Click here for additional data file. (98.6KB, pdf)

Supplementary information.

Click here for additional data file. (107.4KB, pdf)

Data Availability Statement

All data generated or analyzed during this study are included in this published article.

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