Older, frail heart attack patients at greater risk of bleeding

Many older patients who are considered frail by medical standards receive anticoagulants (blood thinners) and undergo cardiac catheterization during a heart attack. While these treatments can be helpful, they also can cause major bleeding, and frailty is an important bleeding risk factor according to a study published today in in JACC: Cardiovascular Interventions.

The research found that patients over age 65 who are frail had a 50 percent higher risk of major bleeding when hospitalized during a heart attack than non-frail patients. This risk was seen in frail patients who underwent cardiac catheterization but not those who were managed with medications alone. In the study, frail was classified based on three impairment domains: walking (unassisted, assisted, wheelchair/non-ambulatory), cognition (normal, mildly impaired, moderately/severely impaired), and basic activities of daily living (bathing, eating, dressing, and toileting).

Some smaller studies have looked at frailty in relationship to heart attack and bleeding; however, this is the first study to gather data from the ACTION Registry—now known as the Chest Pain-MI Registry.

"Beginning in 2015, the ACTION Registry began to capture this information, allowing us to have two years' worth of data," said lead study author John A. Dodson, MD, MPH, FACC, a cardiologist and researcher from New York University School of Medicine. "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."

Researchers analyzed 129,330 AMI patients over 65 years of age from 775 U.S. hospitals between January 2015 and December 2016.

The analysis found that patients with AMI who were frail were:

• More likely to be female.
• 50 percent more likely to experience major bleeding.
• Less likely overall to undergo cardiac catheterization.
• Less likely to receive radial access when cardiac catheterization was performed.
• At higher risk of bleeding when cardiac catheterization was performed, but not when treated with medications alone.

"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 said. "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 evidenced-based clinical strategies to avoid bleeding in this population."

Limitations of the study include that the frailty assessment was based on available elements in the database, and physical measurements of frailty (such as walking speed or grip strength) that were used in previous studies were not obtained. Additionally, the study may have underestimated the prevalence of frailty given its reliance on people documenting frailty in the medical record.