Thanks for Dr. Kawada’s concern . Dr. Kawada raise two important issues regarding our review  the role of prefrailty and gender in the effect of frailty on all-cause mortality in patients with acute coronary syndromes (ACS).
Little attention has been paid to the role of prefrailty on risk assessment in older patients with ACS. It is important to note that the prevalence of comorbidities, the risk conditions, and mortality progressively increased along with the degree of frailty in patients from this series . Therefore, prefrailty should be considered as an intermediate status between robust and frail patients. The earlier stage of frailty is reversible and could be remedied. Nutritional supplement with 25–30 g of high-quality protein per meal have slowed or prevented sarcopenia, a manifestation of prefrailty . Meanwhile, physical activity interventions might play a pivotal role in the prevention of both CVD and frailty. More studies are required to confirm its function and establish standard exercise prescriptions. The frailty as a therapeutic goal intervened by non-pharmacological means is the future hotspot of research.
The prevalence of frailty in older patients is about twice in women than in men. Female sex is an independent predictor of frailty in elderly patients with ACS, and it is also associated with higher mortality . Several differences could explain this sex-related difference. The association of female sex with more atypical symptoms. Older women without a typical chest pain are commonly underdiagnosed and mistreated. A study showed that women have lower revascularization rates than men , and these patients who do not undergo coronary angiography and revascularization seem to have worse prognosis. Further studies are needed to elucidate the best management of frail older women with ACS.