Frailty increases bleeding risk after TAVR, surgical AVR
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Frailty was linked to postprocedural bleeding in older patients undergoing transcatheter aortic valve replacement or surgical AVR, according to a study published in JACC: Cardiovascular Interventions.
This also increased the risk for midterm mortality, according to the study.
“Although technical procedural factors remain the most direct determinants of bleeding complications, the aforementioned patient-level risk factors should be carefully considered by the heart team in the management of these vulnerable patients,” Melissa Bendayan, MSc, master’s student in the division of experimental medicine at McGill University in Montreal at the time of the study and is now an MD student at Tel Aviv University, and colleagues wrote.
FRAILTY-AVR trial data
In this post hoc analysis of the FRAILTY-AVR trial, researchers assessed data from 1,195 patients aged at least 70 years with severe aortic stenosis who underwent TAVR (n = 747; mean age, 83 years; 45% women; mean Society of Thoracic Surgeons Predicted Risk of Mortality, 6.1%) or surgical AVR (n = 448; mean age, 78 years; 36% women; mean STS Predicted Risk of Mortality, 3.4%).
Several frailty scales were used to predict bleeding outcomes, including the Essential Frailty Toolset (EFT), the Fried scale, the Rockwood Clinical Frailty Scale, Short Physical Performance Battery and the Columbia scale.
The primary endpoint was life-threatening or major bleeding during the index hospitalization. The secondary endpoint was defined as the number of packed red blood cell units transfused.
A significant number of patients who underwent TAVR or surgical AVR had life-threatening bleeding (3% vs. 8%, respectively), major bleeding with an apparent source (6% vs. 10%, respectively) and major bleeding without an apparent source (9% vs. 31%, respectively).
The EFT was an independent predictor of major bleeding in the TAVR (OR = 1.66 per EFT point; 95% CI, 1.38-1.98) and the surgical AVR groups (OR = 1.68 per EFT point; 95% CI, 1.36-2.09). This score was also an independent predictor for packed red blood cell transfusions for patients who underwent TAVR (beta = 0.46 per EFT point; 95% CI, 0.28-0.64) or surgical AVR (beta = 0.71 per EFT point; 95% CI, 0.41-1.01).
Major bleeding was linked to an increase in mortality at 1 year after TAVR (OR = 3.4; 95% CI, 2.22-5.21) and surgical AVR (OR = 2.79; 95% CI, 1.25-6.21).
“Frailty, when defined using the EFT, is an incremental yet underrecognized risk factor to help predict bleeding complications and packed red blood cell transfusions,” Bendayan and colleagues wrote. “Components of the EFT can be targeted to reduce the morbidity associated with bleeding complications, namely correction of preexisting anemia, nutritional optimization and physical prehabilitation.”
Improving frailty before procedures
In a related editorial, Tim Kinnaird, MD, interventional cardiologist at University Hospital of Wales in Cardiff, United Kingdom, wrote: “Although frailty could well be improved by preprocedural intervention, it does not necessarily follow that this would reduce bleeding. Much of the comorbid burden associated with age and frailty place patients at risk of periprocedural bleeding, and these may not be modified by the strategies suggested.” – by Darlene Dobkowski
Disclosures: Bendayan and Kinnaird report no relevant financial disclosures. Please see the study for all other authors’ relevant financial disclosures.
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Bendayan M. et al. JACC Cardiovasc Interv. 2020;doi:10.1016/j.jcin.2020.01.238.
Kinnaird T. JACC Cardiovasc Interv. 2020;doi:10.1016/j.jcin.2020.02.021.
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