Comparing health outcomes between coronary interventions in frail patients aged 75 years or older with acute coronary syndrome: a systematic review

• Acute coronary syndrome (ACS) mortality is high in the elderly (≥75 years) patient group. Additionally, frailty is known to be associated with poor clinical outcomes. With the number of elderly patients presenting with ACS expected to rise, studies are needed to inform optimal strategies of care for these patients 

• This review aimed to assess the available evidence comparing the different coronary interventions in frail patients aged ≥75 years 

• The findings show that current available evidence is insufficient to inform optimal ACS care in the elderly and frail population. There is therefore a need for more robust studies in the future 

This systematic review searched literature from Scoupus, Embase and PubMed in May 2022. All methods employed in the study matched PRISMA recommendations for systematic reviews and meta-analyses. 

• Any health outcome (e.g. all cause death, recurrent myocardial infarction, quality of life, etc) 

• Aged ≥75 years 

• Assessed level of frailty at baseline 

• Any ACS presentation 

• Any coronary intervention strategy or reperfusion treatment 

• Comparison of outcomes between any two interventions from primary research 

• Total of 9 studies, across 5 countries, met the inclusion criteria 

• Three studies observed benefit of percutaneous coronary intervention (PCI) vs no PCI 

  • PCI reduced 1-year mortality (hazard ratio (HR): 0.38 [95% confidence interval (CI) 0.27–0.53]; P<0.001)  

  • PCI conferred lower risk of long-term all-cause readmission (Incidence Rate Ratio: 0.6 [95% CI 0.43–0.84]) 

  • PCI treated frail patients had reduced risk of in-hospital mortality (OR: 0.59 [95% CI 0.55–0.63]) 

• Coronary artery bypass graft (CABG) reduced risk of in-hospital mortality compared to no PCI (OR = 0.77 [95% CI = 0.65–0.93])  

• Numerical differences of in-hospital mortality rates (conservative strategy (15%), Angio-MM (12.1%), PCI (16.9%), CABG (12%) and thrombolysis (40%)) 

Currently available research lacks robust statistically significant data to inform optimal care of elderly and frail patients with ACS. There is a paucity of evidence comparing outcomes between coronary interventions in this population. More robust studies are needed. 

• Heterogeneity between the included studies

  • ACS subtypes identified 

  • Frailty assessments used 

  • Coronary interventions compared 

  • Outcomes studied 

• All studies were established to be at high risk of bias, with adjustment for cofounders being poorly reported