Frailty in acute coronary syndrome: From risk stratification to clinical decision-making

Frailty is a common condition among older adults presenting with acute coronary syndrome and is recognized as a significant determinant of both short- and long-term outcomes. This literature review summarizes the concept of frailty and the assessment tools most relevant in acute care. We synthesize evidence linking frailty to mortality, prolonged hospitalization, and procedural complications, and highlight how heterogeneity among different frailty assessment tools has limited comparisons between studies and the incorporation of guidelines. For healthcare professionals, we propose a pragmatic approach: Rapid screening at first contact using a simple, validated tool; targeted multi-domain assessment for those with a positive result; and clear integration of frailty status into shared decision-making regarding interventional strategies, discharge planning, and transitional care. We identify key gaps, most notably the lack of randomized trials stratified by frailty, limited implementation research on frailty-guided care pathways, and the need to standardize metrics for cardiac testing and registries. Integrating frailty assessment into routine acute coronary syndrome care holds promise for improved individualized risk prediction and more patient-centered management, but will require coordinated research, clearer reporting standards, and feasible clinical workflows.