Importance of the Assessment of Physical Frailty in Elderly Japanese Patients With Acute Myocardial Infarction
論文ID: CJ-23-0014
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論文ID: CJ-23-0014
Acute myocardial infarction (AMI) is defined as acute necrosis of myocardial cells caused by prolonged myocardial ischemia.1 Although AMI remains a leading cause of death, the rate of in-hospital death from AMI has decreased as a result of improved percutaneous coronary intervention (PCI) and critical care for AMI in Japan.2 Many elderly patients with AMI have multiple comorbidities, cognitive decline, and frailty; as the Japanese population ages, the number of patients with frailty is also increasing.2 Frailty is a clinical syndrome characterized by increased vulnerability to illness and injury and decreased physiological reserves as a result of aging.3,4 Frailty in patients with AMI is strongly and independently associated with in-hospital and short-term death and the need for prolonged hospital care.5,6 A systematic review and meta-analysis demonstrated that among elderly patients with acute coronary syndrome, frailty significantly increased the risk of all-cause death by 2.65-fold, the risk of any type of cardiovascular disease by 1.54-fold, the risk of major bleeding by 1.51-fold, and the need for hospital readmissions by 1.51-fold.7 According to a recent scientific statement from the Japanese Circulation Society (JCS), the evaluation of frailty is crucial in elderly patients with AMI.8
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In this issue of the Journal, Ashikawa et al9 describe the results of their multicenter cohort investigation (the FLAGSHIP study), which provide useful insight into the stratification of risk for heart failure (HF) development among elderly Japanese patients after AMI. The study cohort included 524 patients aged ≥70 years (median: 76 years; interquartile range: 72–80 years) who were hospitalized for AMI, had no history of HF, and were capable of walking at discharge. The investigators assessed grip strength, usual walking speed, and scores on the 7-item Self-Efficacy for Walking-7 (SEW-7) and the Performance Measure for Activity of Daily Living-8 (PMADL-8). The cutoff value and assigned score for each physical frailty domain were determined by the prognosis of HF in the main analysis of the FLAGSHIP study.10 A total score ≥9 was considered to indicate physical frailty. The results of the study demonstrated that the risk for the composite outcome (all-cause death and rehospitalization for HF) within 2 years of discharge was 2.09-fold higher in patients with physical frailty than in non-frail patients.
The aging process is characterized by increasing oxidative stress and chronic inflammation, which lead to sarcopenia and other multisystemic dysfunction (the “cycle of frailty”)11,12 (Figure). In hospitalized patients, aspects of the hospital environment (i.e., immobilization, fasting, sleep deprivation, and disorientation) can dramatically worsen physical frailty, with rapid, severe loss of muscle mass and function.13 This phenomenon, “posthospital syndrome”, necessitates intervention. According to JCS class I (evidence level A), cardiac rehabilitation via a clinical pathway is recommended during the acute phase of AMI.14 Early intervention with cardiac rehabilitation in patients with AMI can improve the prognosis. Discharge planning should include referral for continued cardiac rehabilitation, which is also a JCS class I (evidence level A) recommendation because of its favorable effects on outcomes.8
Pathological mechanisms underlying physical frailty and interventions to stop the “cycle of frailty”. The aging process is characterized by oxidative stress and chronic inflammation, which leads to sarcopenia and other multisystemic dysfunction (i.e., the cycle of frailty). This cycle can be stopped by interventions such as cardiac and dietary rehabilitation. (Reproduced with permission from Angulo J, et al.11)
Assessment of frailty is important for management and risk stratification of AMI. Numerous tools have been developed to measure frailty, but the “gold standard” measure of functional capacity has not been established because patients with frailty are a clinically heterogeneous population. Moreover, most frailty assessment tools were developed in outpatient settings; thus, in the acute phase, determining whether frailty is potentially reversible is challenging. What, then, is the importance of Ashikawa et al’s study for daily clinical practice? First, physical frailty should be assessed in elderly patients with AMI, even if the physical impairment is mild, for early risk stratification, especially to predict new-onset HF. Second, to evaluate physical frailty accurately during the acute phase of AMI, multiple assessment tools in the routine frailty screening should be used. Ashikawa et al do not specify the percentage of patients with improved or worsening frailty after discharge or of those who underwent PCI during the acute phase. They do point out that intervention studies are needed to establish the causal relationship between physical frailty and prognosis, including the development of HF and all-cause death.
The next step is to examine which type of cardiac rehabilitation or other intervention (e.g., dietary modification) stops the cycle of frailty and improves outcomes in elderly patients after AMI13 (Figure). Evidence-based effective cardiac intervention protocols should then be adapted to daily clinical practice.
All authors declare that they have no conflicts of interest.
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