Advertisement

Comorbidity assessment for mortality risk stratification in elderly patients with acute coronary syndrome

Published:January 31, 2019DOI:https://doi.org/10.1016/j.ejim.2019.01.018

      Highlights

      • Comorbidities are highly prevalent in elderly patients with acute coronary syndrome.
      • A simplified assessment of 6 comorbidities provided useful risk stratification.
      • Three comorbidity categories of progressive 1-year mortality risk were identified.
      • This information might be relevant for personalized management.

      Abstract

      Background

      The Charlson's is the most used comorbidity index. It comprises 19 comorbidities, some of which are infrequent in elderly patients with acute coronary syndrome (ACS), while some others are manifestations of cardiac disease rather than comorbidities. Our goal was to simplify comorbidity assessment in elderly non-ST-segment elevation ACS patients.

      Methods

      The study group consisted of 1 training (n = 920, 76 ± 7 years) and 1 testing (n = 532; 84 ± 4 years) cohorts. The end-point was all-cause mortality at 1-year follow-up. Comorbidities were assessed selecting those medical disorders other than cardiac disease that were independently associated with mortality by multivariable analysis.

      Results

      A total of 130 (14%) patients died in the training cohort. Six comorbidities were predictive: renal failure, anemia, diabetes, peripheral artery disease, cerebrovascular disease and chronic lung disease. The increase in the number of comorbidities yielded a gradient of risk on top of well-known clinical predictors: ≥3 comorbidities (27% mortality, HR = 1.90, 95% CI 1.20–3.03, p = .006); 2 comorbidities (16% mortality, HR = 1.29, 95% CI 0.81–2.04, p = .30); and 0–1 comorbidities (7.6% mortality, reference category). The discrimination accuracy (C-statistic = 0.80) and calibration (Hosmer-Lemeshow test, p = .20) of the predictive model using the 6 comorbidities was comparable to the predictive model using the Charlson index (C-statistic = 0.80; Hosmer-Lemeshow test, p = .70). Similar results were reproduced in the testing cohort (≥3 comorbidities: 24% mortality, HR = 2.37, 95% CI 1.25–4.49, p = .008; 2 comorbidities: 14% mortality, HR = 1.59, 95% CI 0.82–3.07, p = .20; 0–1 comorbidities: 7.5% reference category).

      Conclusion

      A simplified comorbidity assessment comprising 6 comorbidities provides useful risk stratification in elderly patients with ACS.

      Keywords

      Abbreviations:

      ACS (Acute coronary syndrome)
      To read this article in full you will need to make a payment

      Purchase one-time access:

      Academic & Personal: 24 hour online accessCorporate R&D Professionals: 24 hour online access
      One-time access price info
      • For academic or personal research use, select 'Academic and Personal'
      • For corporate R&D use, select 'Corporate R&D Professionals'

      Subscribe:

      Subscribe to European Journal of Internal Medicine
      Already a print subscriber? Claim online access
      Already an online subscriber? Sign in
      Institutional Access: Sign in to ScienceDirect

      References

        • Singh M.
        • Reeder G.S.
        • Jacobsen S.J.
        • Weston S.
        • Killian J.
        • Roger V.L.
        Scores for post-myocardial infarction risk stratification in the community.
        Circulation. 2002; 106: 2309-2314
        • Krumholz H.M.
        • Chen J.
        • Chen Y.T.
        • Wang Y.
        • Radford M.J.
        Predicting one-year mortality among elderly survivors of hospitalization for an acute myocardial infarction: Results from the cooperative cardiovascular project.
        J Am Coll Cardiol. 2001; 38: 453-459
        • Sanchis J.
        • Núñez J.
        • Bodí V.
        • Núñez E.
        • García-Alvarez A.
        • Bonanad C.
        • et al.
        Influence of comorbid conditions on one-year outcomes in non-ST-segment elevation acute coronary syndrome.
        Mayo Clin Proc. 2011; 86: 291-296
        • Chirinos J.A.
        • Veerani A.
        • Zambrano J.P.
        • Schob A.
        • Perez G.
        • Mendez A.J.
        • et al.
        Evaluation of comorbidity scores to predict all-cause mortality in patients with established coronary artery disease.
        Int  J Cardiol. 2007; 117: 97-102
        • Sanchis J.
        • Bonanad C.
        • Ruiz V.
        • Fernández J.
        • García-Blas S.
        • Mainar L.
        • et al.
        Frailty and other geriatric conditions for risk stratification of older patients with acute coronary syndrome.
        Am Heart J. 2014; 168: 784-791
        • Graham M.M.
        • Galbraith D.
        • O’Neill D.
        • Rolfson D.B.
        • Dando C.
        • Norris C.M.
        Frailty and outcome in elderly patients with acute coronary syndrome.
        Can J Cardiol. 2013; 29: 1610-1615
        • Alegre O.
        • Formiga F.
        • López-Palop R.
        • Marín F.
        • Vidán M.T.
        • Martínez-Sellés M.
        • et al.
        An easy assessment of frailty at baseline independently predicts prognosis in very elderly patients with acute coronary syndromes.
        J Am Med Dir Assoc. 2018; 19: 296-303
        • de Groot V.
        • Beckerman H.
        • Lankhorst G.J.
        • Bouter L.M.
        How to measure comorbidity. A critical review of available methods.
        J Clin Epidemiol. 2003; 56: 221-229
        • Charlson M.E.
        • Pompei P.
        • Ales K.L.
        • MacKenzie C.R.
        A new method of classifying prognostic comorbidity in longitudinal studies: development and validation.
        J Chronic Dis. 1987; 40: 373-383
        • Park J.Y.
        • Kim M.H.
        • Bae E.J.
        • Kim S.
        • Kim D.K.
        • Joo K.W.
        • et al.
        Comorbidities can predict mortality of kidney transplant recipients: comparison with the Charlson comorbidity index.
        Transplant Proc. 2018; 50: 1068-1073
        • Sachdev M.
        • Sun J.L.
        • Tsiatis A.A.
        • Nelson C.L.
        • Mark D.B.
        • Jollis J.G.
        The prognostic importance of comorbidity for mortality in patients with stable coronary artery disease.
        J Am Coll Cardiol. 2004; 43: 576-582
        • Sanchis J.
        • Ruiz V.
        • Bonanad C.
        • Valero E.
        • Ruescas-Nicolau M.A.
        • Ezzatvar Y.
        • et al.
        Prognostic value of geriatric conditions beyond age after acute coronary syndrome.
        Mayo Clin Proc. 2017; 92: 934-939
        • Sabatine M.S.
        • Morrow D.A.
        • Giugliano R.P.
        • Burton P.B.J.
        • Murphy S.A.
        • McCabe C.H.
        • et al.
        Association of hemoglobin levels with clinical outcomes in acute coronary syndromes.
        Circulation. 2005; 111: 2042-2049
        • Sanchis J.
        • Ruiz V.
        • Ariza-Solé A.
        • Ruescas A.
        • Bonanad C.
        • Núñez J.
        Combining disability and frailty in an integrated scale for prognostic assessment after acute coronary syndrome.
        Rev Esp Cardiol. 2018; (in press)https://doi.org/10.1016/j.rec.2018.04.020 (2018)
        • Eagle K.A.
        • Lim M.J.
        • Dabbous O.H.
        • Pieper K.S.
        • Goldberg R.J.
        • Van de Werf F.
        • et al.
        A validated prediction model for all forms of acute coronary syndrome: estimating the risk of 6-month postdischarge death in an international registry.
        JAMA. 2004; 291: 2727-2733
        • Ekerstad N.
        • Swahn E.
        • Janzon M.
        • Alfredsson J.
        • Löfmark R.
        • Lindenberger M.
        • et al.
        Frailty is independently associated with short-term outcomes for elderly patients with non–ST-segment elevation myocardial infarction.
        Circulation. 2011; 124: 2397-2404
        • Potts J.
        • Kwok C.S.
        • Ensor J.
        • Rashid M.
        • Kadam U.
        • Kinnaird T.
        • et al.
        Temporal changes in co-morbidity burden in patients having percutaneous coronary intervention and impact on prognosis.
        Am J Cardiol. 2018; 122: 712-722
        • Rashid M.
        • Kwok C.S.
        • Gale C.P.
        • Doherty P.
        • Olier I.
        • Sperrin M.
        • et al.
        Impact of co-morbid burden on mortality in patients with coronary heart disease, heart failure, and cerebrovascular accident: a systematic review and meta-analysis.
        Eur Heart J. 2017; 3: 20-36
        • Huang Y.-Y.
        • Kung P.-T.
        • Chiu L.-T.
        • Tsai W.-C.
        Related factors and incidence risk of acute myocardial infarction among the people with disability: a national population based study.
        Res Dev Disabil. 2015; 36: 366-375
        • Menendez-Colino R.
        • Condorhuaman P.
        • Diez-Sebastian J.
        • Mauleon-Ladrero C.
        • Paredes E.
        • Ferrero-Martinez A.
        • et al.
        One-year mortality related factors in older-old patients admitted with heart failure in six Spanish hospitals.
        Eur Geriatr Med. 2013; 4: S32
        • Núñez J.E.
        • Núñez E.
        • Fácila L.
        • Bertomeu V.
        • Llácer A.
        • Bodí V.
        • et al.
        Prognostic value of Charlson comorbidity index at 30 days and 1 year after acute myocardial infarction.
        Rev Esp Cardiol. 2004; 57: 842-849
        • Radovanovic D.
        • Seifert B.
        • Urban P.
        • Eberli F.R.
        • Rickli H.
        • Bertel O.
        • et al.
        Validity of Charlson Comorbidity Index in patients hospitalised with acute coronary syndrome. Insights from the nationwide AMIS Plus registry 2002–2012.
        Heart. 2014; 100: 288-294
        • Schmidt M.
        • Jacobsen J.B.
        • Lash T.L.
        • Bøtker H.E.
        • Sørensen H.T.
        25 year trends in first time hospitalisation for acute myocardial infarction, subsequent short and long term mortality, and the prognostic impact of sex and comorbidity: a Danish nationwide cohort study.
        BMJ. 2012; 344: e356
        • Quan H.
        • Li B.
        • Couris C.M.
        • Fushimi K.
        • Graham P.
        • Hider P.
        • et al.
        Updating and validating the Charlson comorbidity index and score for risk adjustment in hospital discharge abstracts using data from 6 countries.
        Am J Epidemiol. 2011; 173: 676-682
        • Goldenberg I.
        • Subirana I.
        • Boyko V.
        • Vila J.
        • Elosua R.
        • Permanyer-Miralda G.
        • et al.
        Relation between renal function and outcomes in patients with non-ST-segment elevation acute coronary syndrome: real-world data from the European Public Health Outcome Research and Indicators Collection Project.
        Arch Intern Med. 2010; 170: 888-895
        • The Emerging risk factors collaboration
        Diabetes mellitus, fasting glucose, and risk of cause-specific death.
        N Engl J Med. 2011; 364: 829-841
        • Rothnie K.J.
        • Smeeth L.
        • Herrett E.
        • Pearce N.
        • Hemingway H.
        • Wedzicha J.
        • et al.
        Closing the mortality gap after a myocardial infarction in people with and without chronic obstructive pulmonary disease.
        Heart. 2015; 101: 1103-1110
        • Lawler P.R.
        • Filion K.B.
        • Dourian T.
        • Atallah R.
        • Garfinkle M.
        • Eisenberg M.J.
        Anemia and mortality in acute coronary syndromes: a systematic review and meta-analysis.
        Am Heart J. 2013; 165: 143-153
        • Gaskell H.
        • Derry S.
        • Andrew Moore R.
        • McQuay H.J.
        Prevalence of anaemia in older persons: systematic review.
        BMC Geriatr. 2008; 8
        • Tegn N.
        • Abdelnoor M.
        • Aaberge L.
        • Endresen K.
        • Smith P.
        • Aakhus S.
        • et al.
        Invasive versus conservative strategy in patients aged 80 years or older with non-ST-elevation myocardial infarction or unstable angina pectoris (after Eighty study): an open-label randomised controlled trial.
        Lancet. 2016; 387: 1057-1065
        • Sanchis J.
        • Núñez E.
        • Barrabés J.A.
        • Marín F.
        • Consuegra-Sánchez L.
        • Ventura S.
        • et al.
        Randomized comparison between the invasive and conservative strategies in comorbid elderly patients with non-ST elevation myocardial infarction.
        Eur J Intern Med. 2016; 35: 89-94
        • Núñez J.
        • Ruiz V.
        • Bonanad C.
        • Miñana G.
        • García-Blas S.
        • Valero E.
        • et al.
        Percutaneous coronary intervention and recurrent hospitalizations in elderly patients with non ST-segment acute coronary syndrome: the role of frailty.
        Int J Cardiol. 2017; 228: 456-458
        • Llaó I.
        • Ariza-Solé A.
        • Sanchis J.
        • Alegre O.
        • López-Palop R.
        • Formiga F.
        • et al.
        Invasive strategy and frailty in very elderly patients with acute coronary syndromes.
        EuroIntervention. 2018; 14: e336-e342
        • Sanchis J.
        • Ariza-Solé A.
        • Abu-Assi E.
        • Alegre O.
        • Alfonso F.
        • Barrabés J.A.
        • et al.
        Invasive versus conservative strategy in frail patients with NSTEMI: the MOSCA-FRAIL clinical trial study design.
        Rev Esp Cardiol. 2018; ((in press)https://doi.org/10.1016/j.rec.2018.02.007
        • Jeger R.
        • Jaguszewski M.
        • Nallamothu B.N.
        • Lüscher T.F.
        • Urban P.
        • Pedrazzini G.B.
        • et al.
        Acute multivessel revascularization improves 1-year outcome in ST-elevation myocardial infarction: a nationwide study cohort from the AMIS Plus registry.
        Int J Cardiol. 2014; 172: 76-81