Frailty and its association with conventional risk factors for CAD among elderly patients with acute coronary syndrome.

SUPERVISOR: DR. AMITESH AGGARWAL ASSOCIATE PROFESSOR MEDICINE, UCMS & GTBH PRESENTOR: DR. AMIT KUMAR PG STUDENT

Frailty is a geriatric syndrome of increased vulnerability to stressors due to impairments in multiple interrelated systems as a result of decline in physiological reserve. The domains to define frailty include mobility, strength, balance, motor processing, cognition, nutrition, endurance and physical activity.

Common symptoms of frailty are weight loss, exhaustion, low physical activity, slow walking speed at “usual pace” and low grip strength. Frailty provides a conceptual basis for moving away from organ and disease based approaches toward a health based, integrative one.

RATIONALE Frailty per se acts as a risk factor for ACS over and above conventional risk factors. Frailty also have an impact on prognosis after ACS. The studies of frailty in older patients are very limited in patients presenting with ACS.

AIM OF THE STUDY To study the prevalence of frailty and its association with conventional risk factors for CAD among elderly patients presenting with acute coronary syndrome.

MATERIAL AND METHODS SETTING: The study was conducted in Department of Medicine and Biochemistry, UCMS & GTB hospital. STUDY DESIGN: Cross sectional study PLACE: The subjects were recruited from medicine emergency , medicine wards and Coronary Care Unit (CCU) DURATION: November 2014 – April 2016 CONSENT & ETHICS: Approval from IEC taken Informed written consent taken Confidentiality maintained

PARTICIPANTS INCLUSION CRITERIA: Elderly patients ≥ 60 years of age presenting with any one of the spectrum of ACS (STEMI, UA, NSTEMI) who give their full, voluntary and informed consent for the study. EXCLUSION CRITERIA: Patients who were unable to give responses for the interview or for whom no reliable informant was available to answer the questionnaire.

METHODOLOGY The study was based on questionnaire method in which questions were asked that are included in frailty index. Note was made of all the conventional risk factors present in the study subjects. Socioeconomic and demographic profile of all patients was also considered.

ASSESSMENT OF FRAILTY The assessment was made on the basis of questionnaire as applicable 3 days before presentation. To fulfill our primary objective, frailty was defined on the basis of previously validated frailty criteria reported by Fried et al as the presence of 3 out of following 5:-

FRIED CRITERIA A. Unintentional weight loss: Self reported unintentional weight loss of more than 5 kg in last one year. B. Slowness: based upon time to walk 15 feet, adjusting for gender and height. C. Weakness: Weakness is defined by grip strength stratified by gender and body mass index (BMI) quartiles as given by Fried et al. Grip strength was measured by dynamometer.

D. Exhaustion: Exhaustion is defined as present if subjects answered “some difficulty”, “much difficulty” or “unable to do” when asked about how much difficulty they have “walking from one room to another on the same level”. E. Low physical activity: Low physical activity is defined as present if the subjects felt less active as compared to most men/women of their age.

Frailty score was calculated for each of the patient Frailty score was calculated for each of the patient. Patients fulfilling three out of five criteria were labelled as frail and patients with score 1 or 2 were labelled as pre-frail.

RESULTS

Age distribution of the study subjects (n=100)

Demographic profile S.N. Characteristics n % 1. Gender Male 73 Female   Male 73 Female 27 2. Religion Hindu 72 Muslim 25 Christian 2 Sikh 1

Distribution of Frailty status as per Fried’s criteria among subjects (n=100)

Occurrence of conventional risk factors in study subjects (n=100) S. No. Characteristics Present Absent n % 1. Family history of CAD 29 71 2. Smoking habits 70 30 3. Hypertension 57 43 4. Diabetes 39 61 5. Raised waist circumference 36 64 6. Dyslipidemia 92 8

Association of frailty with conventional risk factors S.N. Risk factor Status (+/- ) Presence of frailty n (%) P value No Yes 1. Smoking Absent 20 (60.6%) 13 (39.4%) 0.332 Present 36 (53.7%) 31 (46.3%) 2. Hypertension 23 (53.5%) 20 (46.5%) 0.660 33 (57.9%) 24 (42.1%) 3. Diabetes 36 (59%) 25 (41%) 0.447 20 (51.3%) 19 (48.7%)

4. Family history of CAD Absent 41 (57.7%) 30 (42.3%) 0.582 Present 15 (51.7%) 14 (48.3%) 5. Abnormal waist circumference 34 (53.1%) 30 (46.9%) 0.440 22 (61.1%) 14 (38.9%) 6. Dyslipidemia 5 (62.5%) 3 (37.5%) 0.699 51 (55.4%) 41 (44.6%)

CONCLUSION Occurrence of frailty in elderly patients presenting with acute coronary syndrome in a tertiary care hospital in Delhi was found to be 44%. Statistically significant association of frailty with conventional risk factors for CAD was not observed.

In a study done by Alonso et al, 35 In a study done by Alonso et al, 35.1% of the patients were frail and frailty phenotype was found to be an independent predictor of major adverse cardiac events. In another study done by Kang et al, 43.18% patients were frail and frailty was found to be strongly and independently associated with risk for the primary composite outcomes in cardiac patients.

Frailty might be taken as an independent risk factor for CAD over and above the conventional risk factors for CAD.

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