Gait Speed test in physically frailty patients with ST-segment elevation myocardial infarction| JOURNAL OF GERONTOLOGY AND GERIATRICS

Abstract

Coronary artery disease (CAD) is the most frequent cause of death worldwide and, approximately. Age is an
important determinant of outcomes for patients with ST-segment elevation myocardial infarction (STEMI). Older
adults are at particular risk of developing frailty, a biological syndrome of decreased physiological reserves
resulting in increased vulnerability to stressors. When exposed to such stressors, frail patients are at risk for
decompensation, adverse events, procedural complications, prolonged recovery, functional decline, disability
and mortality. Frailty has become a priority section in cardiovascular medicine because of the aging and the
comorbidities of these patients. There is no upper age limit with respect to reperfusion, especially with PPCI.
In a 2013 study, Yasushi Matsuzawa et al. evidenced that slow gait speed was strongly associated with future
cardiovascular events in STEMI patients who underwent successful primary percutaneous coronary intervention
(PPCI). On the basis of existing literature, we may speculate that STEMI patients with frailty should be
studied with 5 metres gait speed test before hospital discharge, for a better evaluation of physical status. The
results of the test might indicate how to set the pharmacological strategy, cardiac rehabilitation and the time of
follow-up, for improving quality of life of the patients, reducing mortality and hospitalization.

BACKGROUND

Coronary artery disease (CAD) is the most frequent cause of death worldwide and, approximately, accounts for 1.8 million annual deaths in Europe, with naturals variations between countries ¹. The relative incidence of ST-segment elevation myocardial infarction (STEMI) is decreasing but mortality and hospitalization for acute coronary syndrome (ACS) continue to be a elevated ¹. The mortality in STEMI patients is influenced by many factors, among them: advanced age, Killip class, time delay to treatment, presence of emergency medical system (EMS)-based STEMI networks, treatment strategy, history of ACS, diabetes mellitus, renal failure, number of diseased coronary arteries and left ventricular ejection fraction (LVEF).

In particular, age is an important determinant of outcomes for patients with STEMI.

In fact, medically and surgically treated cardiovascular disease (CVD) lead the patients to a frailty status, but many patients are already frails before CVD ².

Older adults are at particular risk of developing frailty, a biological syndrome of decreased physiological reserves resulting in increased vulnerability to stressors. Stressors are broadlyclassified as acute or chronic illness (e.g., myocardial infarction) or iatrogenic (e.g., cardiac surgery) ^{2 3}. When exposed to such stressors, frail patients are at risk for decompensation, adverse events, procedural complications, prolonged recovery, functional decline,disability and mortality. Frailty has become a priority section in cardiovascular medicine because of the aging and the comorbidities of these patients ².

In the general critical care setting, about one-third of older adults are frails and frailty is associated with increased morbidity, mortality, and resource use, such as length of critical care unit stay and readmission rate ^{2 4}. The adverse outcomes associated with frailty and CAD are clearly demonstrated in the existing literature and it is known that frailty patients with CAD have an higher risk of death and re-hospitalization for CVD.

FRAILTY ASSESSMENT

There are over 20 frailty tools to measure frailty. Most tools focus on 1 or more of the 5 core domains that define the frailty phenotype: slowness, weakness, low physical activity, exhaustion, and shrinking. Slowness is measured by a comfortable-pace gait speed test, weakness by a maximal handgrip strength test (using a dynamometer), and other domains by questionnaire or more specialized instruments ⁵.

These domains may be considered individually or combined into a variety of scales. The Fried scale encompasses slowness, weakness, low physical activity, exhaustion, and shrinking (unintentional weight loss), with ≥ 3 of 5 criteria required for a diagnosis of frailty. This is the most frequently cited frailty scale and has been demonstrated to predict mortality and disability in large cohorts of elderly patients with CVD.

Whether cognition and mood should be considered as the sixth and seventh domains of frailty or as modulating factors remains an area of discussion ^{5 6}.

There is a large and increasing body of evidence indicating that the prognosis of older patients is strongly related to the presence of concomitant diseases and to the degree of physical, cognitive, biological, and social impairment ^6-10. A multidimensional assessment is known to be useful for evaluating prognosis in these subjects ^{8 10}.

The Short Physical Performance Battery (SPPB) encompasses slowness, weakness, and balance.

This is measured by a series of 3 timed physical performance tests (gait speed, chair rises, and tandem balance), each is scored 0 to 4 and a total score ≤ 5 of 12 is required for a diagnosis of frailty. In contrast to these multi-item frailty scales, 5-metres gait speed test has been proposed as a single-item measure of phisical frailty ¹¹.

FRAILTY STATUS WITH CARDIOVASCULAR DISEASES PROGNOSIS

Frail patients with CVD have a worse prognosis than non-frail patients. In 2011 study, 628 patients ≥ 65 years who underwent PCI at the Mayo Clinic, 3-year mortality was 28% for frail patients compared with 6% for non-frail patients using the Fried criteria ^{12 13}.

Frailty is strongly and independently associated with a risk for short-term outcomes for elderly Non ST-segment Elevation Myocardial Infarction) NSTEMI patients, including in-hospital mortality, 1-month mortality, prolonged hospital care ^{14 15}.

Identifying frailty has important implications for clinical care. The presence of frailty, worse health status, and more comorbid conditions identify a subset of elderly patients at higher risk of dying during the follow-up, even after a successful procedure ⁵.

The magnitude of risk associated with the frailty, comorbidity, and poor quality of life is greater than predicted from the risk models derived from conventional risk variables.

Identifying frailty can also prompt more comprehensive geriatric evaluation, and interventions to improve functional status. Reducing frailty is likely to both improve clinical outcomes and decrease healthcare utilization and costs ⁵. Frailty is a strong predictor of mortality in patients with chronic heart failure. In patients admitted to hospital with acute decompensated heart failure, simple measures of physical function have been associated with length of hospital stay, reduced activities of daily living, higher readmissions, and mortality ^16-18.

In patients with severe symptomatic aortic stenosis treated by TAVR, frailty predicts need for institutional care and mortality 6–12 months after a successful procedure ^19-21.

FRAILTY STATUS AND STEMI

Frail patients receive lower rates of invasive cardiac care during ACS hospitalization. In a 2018 study, the investigators utilized the CONCORDANCE registry database to report the prevalence of frailty in older adults presenting with ACS ²².

Increased frailty was independently associated with increased postdischarge all-cause mortality but not cardiac-specific mortality ^2-4. These findings inform identification of frailty during ACS hospitalization as a potential opportunity to address competing risks for mortality in this high-risk population. The SILVER-AMI Study evaluated the impact of frailty alongside other risk factors in older adults hospitalized with acute myocardial infarction (AMI), for creating a more personalized assessment of risk and identify potential targets for interventions ²³.

In a 2013 study, Yasushi Matsuzawa et al. evidenced that slow gait speed was strongly associated with future cardiovascular events in STEMI patients who underwent successful primary percutaneous coronary intervention (PPCI) ²⁴.

These findings indicated that the clinical assessment of gait speed could identify the subsets of patients at a higher risk for cardiovascular events after STEMI ²⁴. Interestinginly, in a 2010 and 2016 study, Afilalo J. et al. showed how gait speed test may predict mortality in older adults, after cardiac surgery ^{25 26}. Therefore, it should be consequential to correlate gait speed test to STEMI evaluation for better tailoring therapy and setting follow-up.

TREATMENT IN FRAILTY STEMI

The leading therapeutic choice in frailty patients with Stemi is PPCI but these patients may present with atypical symptoms, the diagnosis of STEMI may be delayed or missed. In addition, the elderly have more comorbidities and are less likely to receive reperfusion therapy compared with younger patients ^{27 28}.

Elderly and frailty patients are also at particular risk of bleeding and other complications from acute therapies because bleeding risk increases with age, renal function tends to decrease, and the prevalence of comorbidities is strong. Observational studies have shown frequent excess dosing of antithrombotic therapies in elderly and frailty patients ^{29 30}. These observational studies, principally focused their attention on NSTEMI but they decribe in STEMI too.

Furthermore, these patients have a higher risk of mechanical complications. It is important to use specific strategies to reduce bleeding risk; these include paying attention to proper dosing of antithrombotic therapies, particularly in relation to frailty status. It is better to use radial access whenever possible. There is no upper age limit with respect to reperfusion, especially with PPCI.

GAIT SPEED TEST IN THE CARDIOVASCULAR CARE OF OLDER ADULTS

Gait speed is a quick, inexpensive, reliable measure of functional capacity with well-documented predictive value for major health-related outcomes. Numerous studies have documented gait speed in older people ^31-33.

In a 2014 JACC review, Afilalo J. et al. analyzed that 5-meter gait speed that has been advocated as a single-item measure of frailty ⁵.

The gait speed test has been shown to have excellent inter-rater reliability (intraclass coefficient 0.88 to 0.96) and test-retest reliability (intraclass coefficient 0.86 to 0.91). It is responsive to change, with meaningful improvements in gait speed (estimated at 0.05 to 0.2 m/s) ^{5 32 33} predicting positive outcomes on a population level but not necessarily an individual patient level.

The walking distance has varied between 3 and 10 m, although the distance has little effect on measured speed ³⁴. The 5-metres distance has been adopted by large registries and is a goodbalance between allowing patients to achieve a steady walking speed without eliciting cardiopulmonary symptoms, because of its shorter duration ⁵.

The short distance and comfortable pace, in fact, are well below cardiopulmonary limitations, making the focus of this test different than a typical stress test or 6-min walk test ¹².

Finally, slow gait speed, along with other frailty measures, has been associated with all-cause mortality, hospital re-admission, adverse surgical outcomes, and incident disability and cardiovascular disease 5 ^{24 35-37 39.}

The most effective treatment for improving the outcomes of patients with slow gait speed and cardiovascular disease is not clear.

Exercise is the most studied intervention but remains underused because of lack of widespread screening and logistical challenges in designing exercise programs specific to older frail patients. Cardiac rehabilitation (CR) combines exercise and lifestyle interventions, and it is a guideline-recommended therapy after acute myocardial infarction (AMI) ^36-38.

CONCLUSIONS

On the basis of existing literature, we may speculate that STEMI patients with frailty should be studied with 5 metres gait speed test before hospital discharge, for a better evaluation of physical status. In a 2012 study, Cacciatore F et al. showed how EF ≥ 50% and 6MWT ≥ 300 m independently protect against mortality in CABG patients before CR, but their protective role was age dependent. In fact, EF ≥ 50% was protective in adults but not in elderly while 6MWT ≥ 300 m was protective in elderly but not in adult patients ³⁹. In this context, we may speculate that 5 metres gait speed test should be important in phisical frailty patients evaluation.

The results of the test might indicate how to set the pharmacological strategy, CR and the time of follow-up, for improving quality of life of the patients, reducing mortality and Hospitalization ^40-42. Future studies are needed for filling the gap, with particular attention to senescence’s biomarkers.

Figures and tables

Figure 1.Slow Gait Speed Test and Clinical Outcomes in Frailty Patients with STEMI.

References

1. ESC Guidelines for the management of acute myocardial infarction in patients presenting with ST-segment elevation. Eur Heart J. 2017; 00:1-66.
2. Flint K. Which came first, the frailty or the heart disease? Exploring the vicious cycle. J Am Coll Cardiol. 2015;10.
3. Bergman H, Ferrucci L, Guralnik J. Frailty: an emerging research and clinical paradigm issues and controversies. J Gerontol A Biol Sci Med Sci. 2007; 62:731-7.
4. Goldfarb M, Afilalo J, Chan A. Early mobility in frail and non-frail older adults admitted to the cardiovascular intensive care unit. J Crit Care. 2018; 47:9-14.
5. Afilalo J, Alexander KP, Mack MJ. Frailty assessment in the cardiovascular care of older adults. J Am Coll Cardiol. 2014; 63:747-62.
6. Fried LP, Tangen CM, Walston J. Frailty in older adults: evidence for a phenotype. J Gerontol A Biol Sci Med Sci. 2001; 56:M146-56.
7. Gill TM, Gahbauer EA, Han L. Trajectories of disability in the last year of life. N Engl J Med. 2010; 362:1173-80.
8. Clegg A, Young J, Iliffe S. Frailty in elderly people. Lancet. 2013; 381:752-62.
9. Pilotto A, Ferrucci L, Franceschi M. Development and validation of a multidimensional prognostic index for one-year mortality from comprehensive geriatric assessment in hospitalized older patients. Rejuvenation Res. 2008; 11:151-61.
10. Pilotto A, Sancarlo D, Daragjati J. Perspective: the challenge of clinical decision-making for drug treatment in older people. The role of multidimensional assessment and prognosis. Front Med. 2014; 1:61.
11. Guralnik JM, Ferrucci L, Simonsick EM. Lower-extremity function in persons over the age of 70 years as a predictor of subsequent disability. N Engl J Med. 1995; 332:556-61.
12. Singh M, Stewart R, White H.. Importance of frailty in patients with cardiovascular disease. Eur Heart J. 2014; 35:1726-31.
13. Singh M, Rihal CS, Lennon RJ. Influence of frailty and health status on outcomes in patients with coronary disease undergoing percutaneous revascularization. Circ Cardiovasc Qual Outcomes. 2011; 4:496-502.
14. Ekerstad N, Swahn E, Janzon M. Frailty is independently associated with short-term outcomes for elderly patients with non-ST-segment elevation myocardial infarction. Circ Cardiovasc Qual Outcomes. 2011; 124:2397-404.
15. Alexander KP, Roe MT, Chen AY. Evolution in cardiovascular care for elderly patients with non-ST-segment elevation acute coronary syndromes. J Am Coll Cardiol. 2005; 46:1479-87.
16. Volpato S, Cavalieri M, Sioulis F. Predictive value of the short physical performance battery following hospitalization in older patients. J Gerontol A Biol Sci Med Sci. 2011; 66:89-96.
17. Chaudhry SI, McAvay G, Chen S. Risk factors for hospital admission among older persons with newly diagnosed heart failure: findings from the Cardiovascular Health study. J Am Coll Cardiol. 2013; 61:635-42.
18. Pittman JG, Cohen P.. The pathogenesis of cardiac cachexia. N Engl J Med. 1964; 271:453-60.
19. Stortecky S, Schoenenberger AW, Moser A. Evaluation of multidimensional geriatric assessment as a predictor of mortality and cardiovascular events after transcatheter aortic valve implantation. J Am Coll Cardiol. 2012; 5:489-96.
20. Drudi LM, Ades M, Asgar A. Interaction between frailty and access site in older adults undergoing transcatheter aortic valve replacement. J Am Coll Cardiol. 2018; 12(11):2185-92.
21. Afilalo J. Frailty in older adults undergoing aortic valve replacement: the FRAILTY-AVR study. J Am Coll Cardiol. 2017; 70:689-700.
22. Patel A, Goodman SG, Yan AT. Frailty and outcomes after myocardial infarction: insights from the CONCORDANCE registry. JAHA. 2018; 7:e009859.
23. Dodson JA, Geda M, Krumholz HM. Design and rationale of the comprehensive evaluation of risk factors in older patients with AMI (SILVER-AMI) study. BMC Health Serv Res. 2014; 14:506.
24. Matsuzawa Y, Konishi M, Akiyama E. Association between gait speed as a measure of frailty and risk of cardiovascular events after myocardial infarction. J Am Coll Cardiol. 2013; 61:1964-72.
25. Afilalo J, Eisenberg MJ, Morin JF. Gait speed as an incremental predictor of mortality and major morbidity in elderly patients undergoing cardiac surgery. J Am Coll Cardiol. 2010; 56:1668-76.
26. Afilalo J, Kim S, O’Brien S. Gait speed and operative mortality in older adults following cardiac surgery. JAMA Cardiol. 2016; 1:314-21.
27. Toleva O, Ibrahim Q, Brass N. Treatment choices in elderly patients with ST: elevation myocardial infarction-insights from the Vital Heart Response registry. Open Heart. 2015; 2:e000235.
28. Malkin CJ, Prakash R, Chew DP. The impact of increased age on outcome from a strategy of early invasive management and revascularisation in patients with acute coronary syndromes: retrospective analysis study from the ACACIA registry. BMJ Open. 2012; 2:e000540.
29. Alexander KP, Chen AY, Roe MT, CRUSADE Investigators. Excess dosing of antiplatelet and antithrombin agents in the treatment of non-ST-segment elevation acute coronary syndromes. JAMA. 2005; 294:3108-116.
30. Bueno H, Betriu A, Heras M, TRIANA Investigators. Primary angioplasty vs fibrinolysis in very old patients with acute myocardial infarction: TRIANA (TRatamiento del Infarto Agudo de miocardio eN Ancianos) randomized trial and pooled analysis with previous studies. Eur Heart J. 2011; 32:51-60.
31. Peel NM, Kuys SS, Klein K.. Gait speed as a measure in geriatric assessment in clinical settings: a systematic review. J Gerontol A Biol Sci Med Sci. 2012; 68:39-46.
32. Hardy SE, Perera S, Roumani YF. Improvement in usual gait speed predicts better survival in older adults. J Am Geriatr Soc. 2007; 55:1727-34.
33. Perera S, Mody SH, Woodman RC. Meaningful change and responsiveness in common physical performance measures in older adults. J Am Geriatr Soc. 2006; 54:743-9.
34. Rikkert MGM, van Iersel MB, Munneke M. Gait velocity and the timed-up-and-go test were sensitive to changes in mobility in frail elderly patients. J Clin Epidemiol. 2008; 61:186-91.
35. Dumurgier J, Elbaz A, Ducimetière P. Slow walking speed and cardiovascular death in well functioning older adults: prospective cohort study. BMJ. 2009; 339:b4460.
36. Anderson L, Thompson DR, Oldridge N. Exercise-based cardiac rehabilitation for coronary heartdisease. Cochrane Database System Rev. 2016;CD001800.
37. Flint K, Kennedy K, Arnold SV. Slow gait speed and cardiac rehabilitation participation in older adults after acute myocardial infarction. JAHA. 2018; 7:e008296.
38. Dodson JA, Arnold SV, Gosch KL. Slow gait speed test and risk of mortality or hospital readmission after myocardial infarction in the translational research investigating underlying disparities in recovery from acute myocardial infarction: Patients’ Health Status registry. J Am Geriatr Soc. 2016; 64:596-601.
39. Cacciatore F, Abete P, Mazzella F. Six-minute walking test but not ejection fraction predicts mortality in elderly patients undergoing cardiac rehabilitation following coronary artery bypass grafting. Eur J Prev Cardiol. 2012; 19:1401-9.
40. Herrman M, Witassek F, Erne P. Impact of cardiac rehabilitation referral on one-year outcome after discharge of patients with acute myocardial infarction. Eur J Prev Cardiol. 2018;26138-44.
41. Lawler PR, Filion KB, Eisenberg MJ. Efficacy of exercise-based cardiac rehabilitation post-myocardial infarction: a systematic review and meta-analysis of randomized controlled trials. Am Heart J. 2011; 162:571-84.e2.
42. Parashar S, Spertus JA, Tang F. Predictors of early and late enrollment in cardiac rehabilitation, among those referred, after acute myocardial infarction. Circulation. 2012; 126:1587-95.