In a national study, investigators reported that although frailty may be more common in women hospitalized with acute myocardial infarction, its association with mortality is stronger in men.
The investigators analyzed 931,133 adult patients admitted with acute myocardial infarction (AMI) in England and Wales between 2005 and 2019 using data from the Myocardial Ischaemia National Audit Project, which was linked to hospital and mortality records. Frailty was assessed with the Secondary Care Administrative Records Frailty (SCARF) index and categorized as fit, mild, moderate, or severe. The primary outcome was all-cause mortality at 1 year.
Among the overall cohort, 34.1% identified as female. Severe frailty was more prevalent among female patients compared with male patients (16.7% vs 10.4%), and female patients were older within each frailty category. However, male patients within the same frailty strata had a higher burden of atherosclerosis-related comorbidities and were more likely to present with acute instability, including cardiac arrest.
Treatment patterns also differed, according to the investigators. Across frailty categories, male patients were more likely to receive invasive coronary angiography, percutaneous coronary intervention, and guideline-directed medical therapy. Despite this, frailty carried a greater relative mortality risk in male patients.
After multivariable adjustment, severe frailty was associated with a 26% greater relative increase in 1-year mortality in male patients compared with female patients. This translated to an adjusted absolute risk difference of 1.19%, indicating a higher predicted probability of mortality among severely frail male patients following AMI.
“In this national AMI cohort, while frailty was more prevalent in females, its association with 1-year mortality was significantly greater in males,” wrote lead study author Hasan Mohiaddin, of the National Institute for Health Research Leicester Biomedical Research Centre and British Heart Foundation Centre of Research Excellence as well as the Keele Cardiovascular Research Group at the Centre for Prognosis Research at the Keele University School of Medicine in the United Kingdom, and colleagues.
The investigators described this pattern as a “sex-frailty paradox,” noting that frailty was more common in female patients but linked to more severe outcomes in male patients.
The interaction was consistent across ST-segment elevation myocardial infarction (STEMI) and non–STEMI presentations and persisted at 30 days. For 30-day all-cause mortality, severe frailty was associated with a 23% higher relative risk in male patients compared with in female patients.
The study authors concluded that the disparity “is not explained by differences in the intensity of care” and suggested that “the biological meaning of a frailty diagnosis in the context of an AMI differs between the sexes.” They added that the findings could challenge a one-size-fits-all approach to risk assessment and underscored the need to integrate both frailty status and sex into clinical evaluation to facilitate more precise care pathways.
The study authors reported no conflicts of interest related to the present study. Full disclosures can be found in the study.
