Frailty is common in older patients undergoing percutaneous coronary intervention (PCI) in the US, with a “clear gradient of increasing risk” based on frailty status, according to a new registry analysis of more than 1.3 million patients. The researchers — led by Benjamin Peterson, MD, MPH, from the University of Kentucky School of Medicine, and Ajar Kochar, MD, MHS, from Brigham and Women’s Hospital, Boston, and Duke University School of Medicine, Durham — concluded that systematic assessment of frailty prior to PCI is therefore “likely to inform shared decision-making in a more precise manner”. The findings were published Monday online ahead of the June 24 issue of the Journal of the American College of Cardiology. More than half of PCI procedures occur in over 65s, with 80% of total PCI mortality occurring in this group, the authors noted. Yet, while frailty or biologic age reflect cumulative physiological decline and vulnerability to stressors, limited data have been generated on frailty prevalence among US PCI patients, with previous mortality risk scores excluding frailty, they said. The current study therefore set out to investigate the prevalence of frailty among PCI patients and how frailty plays into decision-making using records from the National Cardiovascular Data Registry (NCDR) CathPCI registry. It included the1.32 million patients aged 65 years or older undergoing PCI from October 2018 to December 2021, with frailty assessed using the Canadian Study of Health Aging (CFS), categorizing frailty across 9 strata representing the clinician-reported value of the patient’s functional status over the 2 weeks before PCI. Patients were categorized as having no frailty (CFS 1-2, 78,921 patients or 6%), prefrail (CFS 3-4, 892,695 patients or 67.8%), Frail (CFS 5-6, 284,444 or 21.6%) or severely frail (CFS 7-9, 60,330 or 2.2%). The overall mean age was 74.6 years, 34% were female and common comorbidities included hypertension in 89%, diabetes in 42.5% and prior PCI in 43.5%. The rate of frailty in this study was consistent over time, accounting for 26.4% in April 2018 versus 25.4% in June 2021 following the advent of the Covid-19 pandemic (P = 0.5). Frail patients were older (mean age of 72.6 years for non-frail, 74.1 years for prefrail, 76.3 years for frail and 76 years for severely frail), and more likely to be female (25.8% female in the non-frail cohort, 32.6% in prefrail, 39.4% in frail and 39.4% in severely frail). The most frequent PCI indication for the frail was non–ST-segment elevation myocardial infarction (47.1%), whereas for severely frail patients it was ST-segment elevation myocardial infarction (40.7%). Risk rises with frailty level In hospital mortality was 2.4% for all patients, 0.5% for non-frail (reference), 1.1% for prefrail (odds ratio [OR]: 1.6; 95% confidence interval [CI]: 1.42-1.8), 3.3% for frail (OR: 2.58; 95% confidence interval [CI]: 2.29-2.91) and 20.3% for the severely frail (OR: 5.14; 95% confidence interval [CI]: 4.56-5.8; with an adjusted P value of interaction across all groups of <0.001). Risk of cardiac arrest, cardiac shock and chronic total occlusion and left main coronary intervention all rose significantly with worsening frailty (adjusted P value of interaction <0.001 for all). There was also a consistent gradient of higher rates of adverse clinical events per increasing frailty status, including; bleeding rates (1% for non-frail patients, 1.5% for prefrail, 3.3% for frail and 8.9% for severely frail); need for transfusions (1% for non-frail, 1.9% for prefrail, 5.2% for frail, and 14.7% for severely frail). “This increasing risk was seen in all other complications,” the researchers said. In particular, the researchers stressed that, while small, the severely frail category represented an “exceptionally high risk”. “Severely frail patients experienced strikingly high mortality rates for complex PCI procedures including cardiac arrest (44.2%), cardiogenic shock (51.0%), mechanical circulatory support (46.1%), chronic total occlusion (CTO) (23.9%), left main coronary intervention (29.6%), and severe calcification (22.4%),” the authors said. Across the frailty spectrum, the mortality rates and adjusted association for patients with cardiogenic shock were 20.8% in non-frail patients (reference), 28.9% in prefrail (adjusted OR: 1.33; 95% CI: 1.08-1.64; P < 0.01), 33.8% in frail (adjusted OR: 1.54; 95% CI: 1.25-1.90; P < 0.01) and 51.0% in severely frail (adjusted OR: 2.44; 95% CI: 1.99-3.00; P < 0.01). “These data showing the association of frailty with mortality risk should not justify withholding PCI, especially in acute coronary syndromes. However, frailty status, even prefrailty, strongly influences procedural risk and should inform shared decision making,” the researchers said. Move beyond frailty and risk prediction, editorialists warn However, in an accompanying editorial, John A. Dodson, MD, MPH, from the New York University Grossman School of Medicine, and Ashok Krishnaswami, MD, MAS, from Kaiser Permanente San Jose Medical Center, stressed that: “Ultimately […] recognizing frailty is only useful if it leads to deliberate action. “In some cases, this recognition may reinforce the decision to proceed with a planned intervention; in others, it may prompt reconsideration or even deferral of an invasive procedure in light of its risks.” They added that the cardiology community would be “well served” to move beyond frailty and risk prediction, in any case, since this is “well established,” and “pursue rigorous randomized clinical trials that focus on to what degree frailty is modifiable, and whether modification of frailty can reduce downstream risk.” They added, “In settings where frailty is not modifiable, then determining optimal ways of counseling patients and their caregivers on expected outcomes is of key importance. “Ultimately this can help us move toward a better health system for older adults — in other words, one that focuses on the maintenance of physical and cognitive function — aligning care with ‘what matters most’ to patients.” Sources: Peterson B, Kochar A, Young R, et al. Effect of Frailty on In-Hospital Mortality and Complications of PCI: An NCDR Registry Report. JACC 2025;85:2416-2420. Dodson JA, Krishnaswami A. Frailty and PCI Outcomes: Turning Registry Insights Into Health System Action. JACC 2025;85:2421-2423. Image Credit: Pixel-Shot – stock.adobe.com