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Acute coronary syndromes or acute frailty syndromes?

In the last few years, the proportion of older patients has increased sharply as a consequence of more longevity, thus resulting in big changes to the epidemiology and pathways of acute coronary syndromes (ACSs). The big picture is now characterised by a greater use of revascularisation therapy in ACS patients aged 75 years and older with reduced inhospital mortality, which is mirrored by the increased presentation of patients with serious comorbidities, chronic or post-event disability and elevated post-discharge mortality. A wide spectrum of older patients could be encountered in daily practice, and frailty rather than age is likely to explain the risk of poor outcomes after ACS. Frailty describes a state of vulnerability due to an agerelated decline in many physiological systems and is associated with a considerably increased risk of falling, disability, hospitalisation and mortality. According to the Fried’s frailty criteria, this phenotype includes weight loss, weak grip strength, exhaustion, slow gait speed and low physical activity. Subjects are considered not to be frail if less than three of the five criteria are present and to be frail if three or more criteria are present. Frailty generally overlaps but it is not determined purely by the magnitude of comorbidities, disabilities, depression, poor quality of life, cognitive decline and dependency in activities of daily living. So characterised, frailty constitutes not only a geriatric syndrome to be diagnosed and treated per se, but also a potential component of risk models. The relevance of frailty has been demonstrated across many cardiovascular diseases (CVDs), mostly concerning cross-sectional association: data from the Longitudinal Aging Study Amsterdam (LASA) suggest that CVD patients, particularly those with heart failure and/or peripheral arterial disease, are more likely to become frail, and the risk of incident frailty from CVD is similar to or even greater than that conferred by chronic lung diseases, arthritis or diabetes. The longitudinal association in CVD patients between frailty and incidental mortality has only recently been figured out. Frailty is a significant predictor of all-cause mortality and hospital re-admissions in heart failure patients, with an increased risk of about 60% and 30%, respectively. Moreover, it was associated with a fourfold increased risk of 30-day mortality and a twofold increased risk of long-term mortality after major vascular surgery, without differences regarding open surgery and endovascular procedures. Frailty is also an independent prognostic marker of mortality and re-infarction in patients admitted due to ACSs during a follow-up of one year, the latter being the usual time horizon of earlier observational studies. In the current issue of the journal, Ekerstad and colleague provided a follow-up after more than 5 years of elderly patients with non-ST-segment elevation myocardial infarction (NSTEMI), according to the presence of frailty. In that study the frailty condition was assessed by using the Canadian Study of Health and Aging clinical frailty scale (CFS), and was found in approximately half of the patients considered. The main message was that in elderly NSTEMI patients, frailty was independently associated with all-cause mortality at long-term follow-up; second, that the association between frailty and long-term mortality became weaker over time, while the association between comorbidity and long-term mortality became stronger. So how should this information be used in clinical practice? Are we starting to evaluate all patients presenting with ACSs for frailty? Indeed, several questions still remain unanswered and limit a clear indication. First, we need to identify frailty tools with a high quality of evidence, user friendly for cardiologists treating ACS patients, to be integrated into or added to other methods for cardiovascular risk estimation. Actually, the availability of several multidimensional