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May 11, 2020

Bleeding Risk and Frailty Evaluated in Older Adults Undergoing Aortic Valve Replacement

May 11, 2020—Frailty is associated with postprocedural major bleeding in older adults undergoing transcatheter aortic valve replacement (TAVR) and surgical aortic valve replacement (SAVR), which is in turn associated with a higher risk for midterm mortality, according to findings from the FRAILTY-AVR study published by Melissa Bendayan, MS, et al in Journal of the American College of Cardiology (JACC): Cardiovascular Interventions (2020;13:1058–68).

According to the investigators, the aim of this study was to examine the value of frailty to predict in-hospital major bleeding and determine its impact on midterm mortality after TAVR or SAVR. They noted that bleeding complications are harbingers of mortality and major morbidity in patients undergoing TAVR or SAVR and, despite the high prevalence of frailty in this population, little is known about its effects on bleeding risk.

As summarized in JACC: Cardiovascular Interventions, the investigators performed a post hoc analysis of the multinational FRAILTY-AVR cohort study, which prospectively enrolled patients ≥ 70 years of age who were undergoing TAVR or SAVR. The cohort consisted of 1,195 patients with a mean age of 81.3 ± 6 years. Trained researchers assessed frailty using a questionnaire and physical performance battery preprocedure and ascertained clinical data from the electronic health record.

The primary endpoint was major or life-threatening bleeding during the index hospitalization, and the secondary endpoint was units of packed red blood cells (PRBC) transfused.

The investigators found the following incidences bleeding for TAVR and SAVR, respectively:

  • Life-threatening bleeding: 3% and 8%
  • Major bleeding with a clinically apparent source: 6% and 10%
  • Major bleeding without a clinically apparent source: 9% and 31%

Additional findings included:

  • Frailty measured using the Essential Frailty Toolset (EFT) was an independent predictor of major bleeding and PRBC transfusions in both groups.
  • Major bleeding was associated with a threefold increase in 1-year mortality after TAVR (odds ratio, 3.4; 95% CI, 2.22–5.21) and SAVR (odds ratio, 2.79; 95% CI, 1.25–6.21).

In JACC: Cardiovascular Interventions, the investigators concluded, “In older adults undergoing TAVR or SAVR, frailty is associated with a greater risk for major bleeding, which in turn is associated with a greater risk for midterm mortality, thus underscoring the need of preventive strategies to reduce bleeding in frail patients.”

They advised, “Frailty, when defined using the EFT, is an incremental yet underrecognized risk factor to help predict bleeding complications and PRBC transfusions. 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. 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.”

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