Gender Differences in Risk Factors, Management, and Outcomes of Elderly Patients With Acute Coronary Syndrome: The Interplay of Frailty.

BACKGROUNDS: Older adults constitute a growing proportion of patients presenting with acute coronary syndrome (ACS); optimal management remains uncertain due to comorbidities, frailty, procedure-related complications.

AIM: This study aimed to identify prognostic determinants and to evaluate the impact of invasive management strategies on short- and long-term outcomes in elderly patients with ACS.

METHODS

We retrospectively analyzed consecutive ACS patients aged ≥ 75 years who underwent coronary angiography. Frailty was assessed within the first 48 h of admission using the Rockwood Clinical Frailty Scale (CFS). Sex-related differences, frailty, treatment strategies (percutaneous coronary intervention [PCI] vs. conservative/medical therapy), predictors of short- and long-term outcomes were assessed. The primary endpoint was all-cause mortality; secondary endpoints included major adverse cardiac and cerebrovascular events (MACCEs).

RESULTS

A total of 627 patients were included (46% women), with non-ST-elevation ACS (NSTE-ACS) as the predominant presentation (66.8%). Patients presenting with ST-elevation myocardial infarction (STEMI) experienced significantly higher in-hospital mortality (19.7% vs.5.7%) and MACCEs rates (50.5% vs. 22%; both p < 0.001) compared with those with NSTE-ACS. In-hospital and 1-year mortality did not differ by sex. Shock, frailty, contrast-induced nephropathy, peak troponin levels as independent predictors of in-hospital mortality, whereas frailty, reduced left ventricular ejection fraction, peak troponin independently predicted long-term mortality. Among patients with NSTE-ACS, PCI was associated with lower in-hospital mortality (3.5% vs. 8.4%; p = 0.040) but higher rates of in-hospital and long-term adverse events, without a significant reduction in 1-year mortality.

CONCLUSIONS

Frailty is a dominant determinant of both short- and long-term mortality and should be systematically incorporated into early risk stratification. A selective, frailty-guided invasive strategy may improve early survival whereas routine intervention appears unjustified given the lack of long-term benefit and increased complication risk.