Radial access PCI, proper dosing could cut bleeding rates for frail MI patients

People who are frail and older than 65 are at a 50 percent increased risk of major bleeding during hospitalizations for heart attack compared to nonfrail patients, according to research published Nov. 19 in JACC: Cardiovascular Interventions.

This finding is important in the current climate of care for acute myocardial infarction (AMI), noted lead author John A. Dodson, MD, MPH, and colleagues. The typical heart attack patient is increasingly older with more comorbidities, yet patients are being treated more aggressively than ever before.

“In the past 2 decades there has been a 10-fold increase in the use of coronary revascularization procedures among the ‘oldest old,’ and recent registry data demonstrate that over one-half of patients undergoing percutaneous coronary intervention (PCI) in the United States are ≥65 years of age,” wrote Dodson, with NYU Langone Health in New York, and coauthors. “Concomitant to the growth in PCI among older adults, there has been an increase in the proportion who receive either dual antiplatelet therapy or ‘triple therapy’ (dual antiplatelet therapy plus oral anticoagulant) at hospital discharge.”

While these approaches have demonstrated efficacy for the AMI population as a whole, concerns remain about their potential for increasing the risk of major bleeding, particularly among frail patients.

To investigate this relationship, Dodson et al. studied 129,330 patients older than 65 who were treated at 775 U.S. hospitals participating in the ACTION registry. Patients were classified as frail or not based on three characteristics: walking, cognition and activities of daily living, with scores for each category ranging from 0 to 2 based on level of impairment. The combined summary score, from 0 to 6, was used to designate patients as fit/well (score of 0), mild frailty (1 to 2) or moderate to severe frailty (3 to 6).

Overall, 16.4 percent of the cohort had any degree of frailty. Fit/well patients experienced bleeding in 6.5 percent of hospitalizations, while those with mild frailty and moderate to severe frailty, respectively, had bleeding rates of 9.4 percent and 9.9 percent.

Upon multivariable adjustment, frailty status was independently associated with bleeding only for patients receiving cardiac catheterization—a 33 percent increased risk for mild frailty and a 40 percent risk increase for moderate to severe frailty. There was no independent connection between frailty and bleeding for patients managed with medications alone.

“These observations underscore that frailty is an important additional risk factor among older adults with AMI managed with an invasive strategy, confirming prior reports from several smaller cohorts,” Dodson and colleagues wrote.

The researchers found the likelihood of undergoing PCI decreased with increasing frailty scores, but there were other care processes that may have increased the odds of bleeding. Excess dosing occurred in 52.3 percent of patients who received heparin and 12.1 percent of patients who were given glycoprotein inhibitors, regardless of frailty status.

In the case of the glycoprotein inhibitors, excessive dosing was more common in patients with moderate to severe frailty (26.7 percent) and mild frailty (22.3 percent) than in nonfrail individuals (10.9 percent). Excess glycoprotein inhibitor dosing was associated with higher odds of causing major bleeding than proper dosing (18.5 percent versus 10 percent).

“Although overdosing on the basis of weight-based thresholds is common in obese individuals, overdosing smaller and frail patients may be especially likely to increase the adverse sequelae of adjustable anticoagulant medications,” the authors noted. “This finding, therefore, represents a potential opportunity to modulate bleeding risk through appropriate medication administration, for example through electronic health record decision support systems.”

Another chance to lower bleeding risk, the authors said, is with the use of radial access PCI. But in this study, only 26 percent of frail patients received that intervention, “despite several randomized trials demonstrating that radial access significantly lowers bleeding risk.”

“Based on the observations made by Dodson et al., clinicians should consider using radial access and dose adjustment of antithrombotic therapies in frail patients with AMI who need invasive procedures,” John A. Bittl, MD, with Florida Hospital Ocala, wrote in an accompanying editorial. “Although radial access might be technically more challenging in frail patients than femoral access, a recent randomized trial in the advanced elderly showed that 90% of patients at least 80 years of age with an acute coronary syndrome successfully had transradial percutaneous coronary intervention, with bleeding in <2%.”

Dodson et al. and Bittl agreed that diagnosing frailty before performing PCI may inform estimations of bleeding risk and factor into clinical decision-making.