Vascular Access Site, Frailty and Outcomes in Older Patients Undergoing Percutaneous Coronary Intervention for Acute Coronary Syndromes

INTRODUCTION: In older patients with acute coronary syndromes (ACS), frailty predicts adverse outcomes, but whether radial access retains its lower complication rate in patients with frailty is unknown. We examined outcomes by access site and frailty status and whether frailty modified the association between access site and outcomes. METHODS: We retrospectively studied 227 consecutive patients aged ≥ 70 years, irrespective of frailty status, who underwent percutaneous coronary intervention for ACS at a single center between January 2014 and June 2016. Frailty was screened at admission with the Dutch safety management system (Veiligheidsmanagementsysteem [VMS]) frailty instrument (frailty: VMS score ≥ 1). Primary endpoints were 1-year all-cause mortality and a 30-day composite outcome of death, vascular complications, bleeding, re-infarction and stroke. Effect modification was tested with interaction terms. RESULTS: Access was femoral in 122 (53.7%) and radial in 105 (46.3%) patients. Of the 222 patients with a VMS score, 78 (35.1%) met frailty criteria. The 30-day composite endpoint occurred in 18.9% of patients with femoral access versus 3.8% with radial access (odds ratio [OR] 0.17, 95% confidence interval [CI] 0.06-0.51); 1-year mortality was 12.3% versus 6.7%, respectively (p = 0.14). The composite OR for radial access was 0.14 (95% CI 0.03-0.65) without frailty and 0.24 (95% CI 0.05-1.21) with frailty (ratio of ORs 1.70, 95% CI 0.19-15.54, p-interaction = 0.64; for 1-year mortality 1.24, 95% CI 0.19-8.33, p-interaction = 0.82). Frailty was associated with longer hospital stay and higher 1-year mortality adjusted for access site (hazard ratio [HR] 2.35, 95% CI 1.01-5.43), but not after further adjustment for age (HR 1.56, 95% CI 0.64-3.76). CONCLUSION: Radial access was associated with markedly fewer early complications while frailty was associated with longer hospitalization and lower 1-year survival, largely explained by age. There was no statistically significant evidence of interaction between frailty and access site, although the interaction analysis was limited by the small number of events. These findings are to be considered hypothesis-generating.