Routine invasive strategy and frailty burden in non-ST-segment elevation acute myocardial infarction

Abstract: Objective To assess the prognostic impact of a routine invasive strategy according to the frailty burden in patients with non-STsegment elevation myocardial infarction (NSTEMI) from the MOSCA-FRAIL clinical trial. Methods: The MOSCA-FRAIL trial randomized 167 frail patients, defined by a Clinical Frailty Scale (CFS) ≥ 4, with NSTEMI to an invasive or conservative strategy. The primary endpoint was the number of days alive and out of hospital (DAOH) one year after discharge. For this subanalysis, we compared the impact of an invasive strategy on the outcomes between vulnerable (CFS = 4, n = 43) and frail (CFS > 4, n = 124) patients. Results: Compared to vulnerable patients, frail patients presented lower values of DAOH (289.8 vs. 320.6, P = 0.146), more readmissions (1.03 vs. 0.58, P = 0.046) and higher number of days spent at the hospital during the first year (10.8 vs. 3.8, P = 0.014). The causes of readmission were mostly non-cardiac (56%). Among vulnerable patients, DAOH were similar regardless of strategy (invasive vs. conservative: 325.7 vs. 314.7, P = 0.684). Among frailest patients, the invasive group tended to have less DAOH (267.7 vs. 311.1, P = 0.117). Indeed, patients with CFS > 4, invasively managed lived 29 days less than their conservative counterparts. In contrast, there were no differences in the subgroup with CFS = 4. Conclusions: Adult patients with frailty and NSTEMI showed different prognosis according to the degree of frailty. A routine invasive strategy does not improve outcomes and might be harmful to the frailest patients.