Key result
Initial invasive strategy improves 1-year quality of life more in frail patients without reducing major events.
Why the study?
Frailty is common among patients with chronic coronary disease and is associated with worse outcomes, but whether it modifies the treatment effect of an initial invasive strategy remains unclear.
Does an initial invasive strategy improve clinical outcomes and health-related quality of life compared to a conservative strategy in patients with chronic coronary disease across different frailty burdens?
RCT (n=5,322)
Does an initial invasive strategy improve clinical outcomes and health-related quality of life compared to a conservative strategy in patients with chronic coronary disease across different frailty burdens?
p-value: p=0.30 for interaction
In patients with chronic coronary disease, a higher frailty burden is associated with greater improvements in health-related quality of life with an initial invasive strategy, without an increased risk of adverse clinical events.
Frailty may identify greater QoL benefit from invasive strategy in chronic coronary disease; hypothesis-generating and should not yet change practice.
Background Frailty is common among patients with chronic coronary disease and is associated with worse outcomes. Methods A pooled, post hoc analysis of the ISCHEMIA and ISCHEMIA‐CKD trials was conducted. Baseline frailty was assessed using a Frailty Index (FI), and participants were categorized into data‐derived tertiles. Multivariable Cox models with multiplicative interaction terms (frailty × treatment arm) were constructed to evaluate whether baseline frailty status modified the treatment effect of the initial invasive (vs conservative) strategy on a composite outcome of cardiovascular death, myocardial infarction, hospitalization for unstable angina, heart failure, or resuscitated cardiac arrest and the secondary outcome of HRQoL (Seattle Angina Questionnaire [SAQ]). Results Among 5322 participants (mean 64 years, 24% female), a high frailty burden (tertile 3 vs. tertile 1) was associated with lower baseline SAQ scores and increased risk of adverse clinical outcomes on follow‐up. Baseline frailty burden did not significantly modify the effect of the initial invasive strategy on the primary composite outcome ( P interaction frailty × intervention arm = 0.30). However, frailty significantly modified the effect of the initial invasive strategy on HRQoL, with higher baseline frailty burden associated with greater improvement in SAQ scores at 1 year with initial invasive (vs. conservative) treatment ( P interaction frailty × intervention arm < 0.001). The treatment effect of an initial invasive vs. conservative strategy on 12‐month SAQ score change was most pronounced in individuals with lower baseline SAQ scores in both higher and lower frailty burden groups. Conclusion Patients with chronic coronary disease with a higher frailty burden are more likely to experience greater improvements in HRQoL with initial invasive management without a higher risk of adverse clinical events. Lower baseline SAQ scores predicted greater improvement in HRQoL with initial invasive management, independent of frailty burden.
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Patel et al. (2025) conducted an RCT in chronic coronary disease (n=5,322). Initial invasive strategy vs. Conservative strategy was evaluated on composite outcome of cardiovascular death, myocardial infarction, hospitalization for unstable angina, heart failure, or resuscitated cardiac arrest (p=0.30 for interaction). An initial invasive strategy improved 1-year quality of life more in patients with higher baseline frailty (P interaction<0.001), without modifying the primary clinical outcome (P interaction=0.30).
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