Beyond Chronological Age: Frailty, Vulnerability, and Invasive Decision-Making in Older Adults with Acute Coronary Syndromes

Figure 1. From Chronological Age to Vulnerability-Informed Decision-Making in Older Adults with Acute Coronary Syndromes. Traditional age-based approaches frequently use chronological age as a surrogate for risk and may contribute to both undertreatment and overtreatment. A vulnerability-based framework incorporates frailty, functional status, cognition, comorbidity burden, social support, and patient goals to guide proportional and individualized treatment strategies throughout the continuum of ACS care. Importantly, this conceptual framework is intended to complement, rather than delay, guideline-directed emergency management. In patients with time-sensitive presentations, particularly ST-segment elevation myocardial infarction (STEMI), multidimensional vulnerability assessment should not postpone urgent reperfusion or other evidence-based invasive therapies.

Figure 2. Frailty Across the Acute Coronary Syndrome Care Continuum. Frailty influences multiple stages of care, including clinical presentation, risk stratification, invasive decision-making, in-hospital management, discharge planning, and long-term follow-up. Assessment of vulnerability at each stage may facilitate patient-centered care and improve outcomes.

Figure 3. Traditional Versus Vulnerability-Based Models of Care in Older Adults with Acute Coronary Syndromes. In traditional models, chronological age frequently drives treatment decisions. In contrast, vulnerability-based care integrates expected benefit, treatment burden, recovery potential, and patient preferences to support proportional care aligned with individual goals.