Frailty first: Rethinking invasive strategies for elderly patients with non-ST-elevation myocardial infarction

The management of non-ST-elevation myocardial infarction (NSTEMI) in elderly patients is increasingly common, yet clinical decision-making remains challenging in the presence of frailty. In a large contemporary analysis, Popat <i>et al</i> examined the impact of frailty on outcomes associated with percutaneous coronary intervention (PCI) in patients aged ≥ 75 years hospitalized with NSTEMI. Frailty was assessed using the hospital frailty risk score, an ICD-10-based tool, and categorized as low, intermediate, or high. Using data from the United States National Inpatient Sample (2021-2022), more than 450000 NSTEMI admissions were analyzed. PCI was associated with reduced in-hospital mortality across all frailty categories, supporting its potential benefit even in very elderly patients. However, the magnitude of survival benefit declined progressively with increasing frailty. Higher frailty was also strongly associated with increased procedural complications, longer hospital stays, and greater healthcare costs. These findings suggest that frailty should not be viewed as an absolute contraindication to PCI, but rather as a key modifier in patient-centered decision-making. Despite limitations inherent to retrospective administrative data, this study highlights the importance of frailty-informed strategies in contemporary NSTEMI management.