Gait speed and dependence in activities of daily living in older adults with severe aortic stenosis

Geriatricians' role in the management of aortic stenosis in frail older patients: a decade later

INTRODUCTION

Increasing evidence supports the implementation of geriatric assessment in the workup of older patients with aortic stenosis (AS). In 2012, an online European survey revealed that geriatricians were rarely involved in the assessment of candidates for transcatheter aortic valve implantation (TAVI). After a "call to action" for early involvement of geriatricians in AS evaluation, the survey was repeated in 2022. Our aim was to investigate whether geriatricians' role changed in the last decade.

METHODS

Online survey conducted between December 16th, 2021, and December 15th, 2022. All members of the European Geriatric Medicine Society were invited to participate. The survey included 26 questions regarding geriatricians' experience with AS and TAVI.

RESULTS

Among 193 respondents (79.8% geriatricians), 73 (38%) reported to be involved in AS evaluation at least once a week. During 2 years prior to the survey, 43 (22.3%) had referred > 50% of their patients with severe AS for TAVI. Age influenced TAVI referral in a considerable proportion of respondents (36.8%). TAVI candidates were mainly referred to specialised cardiac centres with multidisciplinary teams (91.8%), including (47.2%) or not including (44.6%) a geriatrician. A total of 38.9% of respondents reported to be part of a multidisciplinary heart team. Geriatricians were less frequently involved (37%) than cardiologists (89.6%) and surgeons (53.4%) in pre-procedural TAVI management. Cardiologists were more frequently involved (85.5%) than geriatricians (33.7%) and surgeons (26.9%) in post-procedural management.

CONCLUSIONS

Geriatricians' involvement in AS management and multidisciplinary heart teams remains scarce. More efforts should be devoted to implement geriatricians' role in AS decision-making.

Development and validation of a prediction model for early mortality after transcatheter aortic valve implantation (TAVI) based on the Netherlands Heart Registration (NHR): The TAVI-NHR risk model

BACKGROUND

The currently available mortality prediction models (MPM) have suboptimal performance when predicting early mortality (30-days) following transcatheter aortic valve implantation (TAVI) on various external populations. We developed and validated a new TAVI-MPM based on a large number of predictors with recent data from a national heart registry.

METHODS

We included all TAVI-patients treated in the Netherlands between 2013 and 2018, from the Netherlands Heart Registration. We used logistic-regression analysis based on the Akaike Information Criterion for variable selection. We multiply imputed missing values, but excluded variables with >30% missing values. For internal validation, we used ten-fold cross-validation. For temporal (prospective) validation, we used the 2018-data set for testing. We assessed discrimination by the c-statistic, predicted probability accuracy by the Brier score, and calibration by calibration graphs, and calibration-intercept and calibration slope. We compared our new model to the updated ACC-TAVI and IRRMA MPMs on our population.

RESULTS

We included 9144 TAVI-patients. The observed early mortality was 4.0%. The final MPM had 10 variables, including: critical-preoperative state, procedure-acuteness, body surface area, serum creatinine, and diabetes-mellitus status. The median c-statistic was 0.69 (interquartile range [IQR] 0.646-0.75). The median Brier score was 0.038 (IQR 0.038-0.040). No signs of miscalibration were observed. The c-statistic's temporal-validation was 0.71 (95% confidence intervals 0.64-0.78). Our model outperformed the updated currently available MPMs ACC-TAVI and IRRMA (p value < 0.05).

CONCLUSION

The new TAVI-model used additional variables and showed fair discrimination and good calibration. It outperformed the updated currently available TAVI-models on our population. The model's good calibration benefits preprocedural risk-assessment and patient counseling.

The safety of exercise for older patients with severe aortic stenosis undergoing conservative management: A narrative review

The incidence of aortic stenosis (AS) increases with age and is a serious problem in an aging society. In recent years, transcatheter aortic valve implantation (TAVI) has been performed widely; however, older patients may be ineligible for TAVI or surgical treatment because of medical ineligibility. Symptom-based rehabilitation is required for these patients to maintain and improve their physical function and ability to perform activities of daily living. No studies have examined exercise safety for older patients with severe AS who are ineligible for TAVI or surgery. We summarized the safety of exercise for older patients with severe AS, collecting 7 studies on maximal exercise stress tests and 16 studies on preoperative physical examinations. From this review, it may be unlikely that exercise under appropriate management can cause hemodynamic changes, leading to death. However, there were no studies on exercise intervention for older patients with AS who are chosen for conservative management. The optimal exercise intensity for symptomatic older patients with AS undergoing conservative management and the effects of continuous exercise intervention require future study.

Interventions for Frailty Among Older Adults With Cardiovascular Disease: JACC State-of-the-Art Review

With the aging of the world's population, a large proportion of patients seen in cardiovascular practice are older adults, but many patients also exhibit signs of physical frailty. Cardiovascular disease and frailty are interdependent and have the same physiological underpinning that predisposes to the progression of both disease processes. Frailty can be defined as a phenomenon of increased vulnerability to stressors due to decreased physiological reserves in older patients and thus leads to poor clinical outcomes after cardiovascular insults. There are various pathophysiologic mechanisms for the development of frailty: cognitive decline, physical inactivity, poor nutrition, and lack of social supports; these risk factors provide opportunity for various types of interventions that aim to prevent, improve, or reverse the development of frailty syndrome in the context of cardiovascular disease. There is no compelling study demonstrating a successful intervention to improve a global measure of frailty. Emerging data from patients admitted with heart failure indicate that interventions associated with positive outcomes on frailty and physical function are multidimensional and include tailored cardiac rehabilitation. Contemporary cardiovascular practice should actively identify patients with physical frailty who could benefit from frailty interventions and aim to deliver these therapies in a patient-centered model to optimize quality of life, particularly after cardiovascular interventions.

The Physiological Burden of the 6-Minute Walk Test Compared With Cardiopulmonary Exercise Stress Test in Patients With Severe Aortic Atenosis

BACKGROUND

Management of aortic stenosis (AS) relies on symptoms. Exercise testing is recommended for asymptomatic patients with significant AS but is often experienced as forbidding and/or technically unrealistic for patients who are often frail, deconditioned, and intimidated by the exercise test. We compared the physiological burden assessed with gas exchange assessments to gauge and respiratory exchange ratio (RER) of a 6-minute walk test (6MWT) to a cardiopulmonary exercise stress test (CPET) in patients with severe AS. peak oxygen utilization.

METHODS

Adults with equivocal symptoms and severe AS (1-aortic valve area [AVA] ≤ 1.0 cm2 or AVA index ≤ 0.6 cm2/m2, 2-peak aortic jet velocity ≥ 4.0 m/sec, 3-mean transvalvular pressure gradient ≥ 40 mm Hg by rest or dobutamine stress echocardiography, or 4-aortic valve calcification ≥ 1200 in women or ≥ 2000 AU in men) were studied. All participants completed both a 6MWT and symptom-limited progressive bicycle exercise testing. Breath-by-breath gas analysis and 12-lead electrocardiography were completed during 6MWT and CPET. Results: Eleven patients were studied. Patients walked on average 330 ± 75 m during the 6MWT and achieved a maximal workload of 48 ± 14 watts during the CPET. During the 6MWT, peak maximal oxygen uptake (V ˙ O2peak) was 12.8 ± 2.5 vs 10.8 ± 4.2 mL/kg/min during the CPET. Respiratory exchange ratio exceeded 1.1 in both the 6MWT and CPET indicating similarly high exertion. Compared with the CPET, a larger proportion of the 6MWT was performed at a high intensity level (78% ± 28% vs 33% ± 24% at > 85% V̇O2peak; P = 0.004).

CONCLUSIONS

The 6MWT with breath-by-breath gas analysis was well tolerated and able to achieve a physiological intense RER andV ˙ O2peak that are similar to symptom-limited CPET in patients with severe AS.

A Wrist-Worn Sensor-Derived Frailty Index Based on an Upper-Extremity Functional Test in Predicting Functional Mobility in Older Adults

INTRODUCTION

Preoperative frailty is an independent risk factor for postoperative complications across surgical specialties. Functional mobility such as gait, timed up and go (TUG), and 5 times sit-to-stand (5-STS) are popular preoperative frailty measurements but are not suitable for patients with severe mobility impairment. A wrist-worn sensor-derived frailty index based on an upper-extremity functional test (20-s repetitive elbow flexion-extension task; UEFI) was developed previously; however, its association with functional mobility remained unexplored. We aimed to investigate the predictive power of the UEFI in predicting functional mobility.

METHODS

We examined correlation between the UEFI and gait speed, TUG duration, and 5-STS duration in 100 older adults (≥ 65 years) using multivariate regression analysis. The UEFI was calculated using slowness, weakness, exhaustion, and flexibility of the sensor-based 20-s repetitive elbow flexion-extension task.

RESULTS

The UEFI was a significant predictor for gait speed and TUG duration and 5-STS duration (all R ≥ 0.60; all p < 0.001) with the variance (adjusted R2) of 35-37% for the dependent variables. The multivariate regression analysis revealed significant associations between the UEFI and gait speed (β = -0.84; 95% confidence interval [95% CI] = [-1.19, -0.50]; p < 0.001) and TUG duration (β = 16.2; 95% CI = [9.59, 22.8]; p < 0.001) and 5-STS duration (β = 33.3; 95% CI = [23.6, 43.2]; p < 0.001), found after accounting for confounding variables (e.g., age and fear of falling scale).

CONCLUSIONS

Our findings suggest that the UEFI can be performed with a wrist-worn sensor and has been validated with other established measures of preoperative frailty. The UEFI can be applied in a wide variety of patients, regardless of mobility limitations, in an outpatient setting.

Performance of EuroSCORE II and Society of Thoracic Surgeons risk scores in elderly patients undergoing aortic valve replacement surgery

BACKGROUND

In cardiac surgery, risk is estimated with models such as EuroSCORE II and the Society of Thoracic Surgeons (STS) score. Performance of these scores may vary across various patient age ranges.

AIM

To assess the effect of patient age on performance of the EuroSCORE II and STS scores, regarding postoperative mortality after surgical aortic valve replacement.

METHODS

In a prospective cohort of patients, we assessed risk stratification of EuroSCORE II and STS scores for discrimination of in-hospital mortality with the area under the receiver operating characteristic curve (AUROC) and calibration with the Hosmer-Lemeshow test. Two groups of patients were compared: elderly (aged>75years) and younger patients.

RESULTS

Of 1229 patients included, 635 (51.7%) were elderly. Mean EuroSCORE II score was 3.7±4.4% and mean STS score was 2.1±1.5%. Overall in-hospital mortality was 4.8% and was higher in the elderly compared with younger patients (6.6% vs. 2.8%; log-rank P=0.014). AUROC for the EuroSCORE II score was lower in elderly than in younger patients (0.731 vs. 0.784; P=0.025). Similarly, AUROC for the STS score was lower in elderly versus younger patients (0.738 vs. 0.768; P=0.017). In elderly patients, EuroSCORE II and STS scores were not adequately calibrated and significantly underestimated mortality. Age was independently associated with mortality, regardless of EuroSCORE II or STS score.

CONCLUSIONS

In this cohort, EuroSCORE II and STS scores did not perform as well in elderly patients as in younger patients. Elderly patients may be at increased postoperative risk, regardless of risk score.

Factors Associated with Moderate Physical Activity Among Older Adults with Atrial Fibrillation

OBJECTIVE

Engaging patients with atrial fibrillation (AF) in moderate-intensity physical activity has been encouraged by published guidelines. We examined factors associated with engagement in moderate physical activity among older adults with AF.

METHODS

This was a retrospective study involving ninety patients with episodes of Afib with RVR duData are from the SAGE (Systematic Assessment of Geriatric Elements)-AF study. Older adults (≥ 65 years) with AF and a CHA2DS2-VASc ≥ 2 were recruited from several clinics in Massachusetts and Georgia between 2015 and 2018. The Minnesota Leisure Time Physical Activity questionnaire was used to assess whether participants engaged in moderate-intensity physical activity (i.e. at least 150 minutes of moderate exercise). Logistic regression was utilized to examine the sociodemographic and clinical characteristics and geriatric elements associated with engaging in moderate-intensity physical activity.

RESULTS

Participants were on average 76 years old and 48% were women. Approximately one-half (52%) of study participants engaged in moderate-intensity physical activity. Morbid obesity (adjusted OR [aOR]=0.41, 90%CI=0.23-0.73), medical history of renal disease (aOR= aOR=0.68,90%CI= 0.48-0.96), slow gait speed (aOR=0.44, 90%CI=0.32-0.60), cognitive impairment (aOR=0.74, 90%CI=0.56-0.97), and social isolation (aOR=0.58, 90%CI= 0.40-0.84) were independently associated with a lower likelihood, while higher AF related quality of life score (aOR=1.64, 90%CI=1.25-2.16) a greater likelihood, of meeting recommended levels of moderate physical activity.

CONCLUSIONS

Nearly one-half of older adults with NVAF did not engage in moderate-intensity exercise. Clinicians should identify older patients with NVAF who are less likely to engage in physical activity and develop tailored interventions to promote regular physical activity.

Preoperative Cognitive Impairment and Postoperative Delirium Predict Decline in Activities of Daily Living after Cardiac Surgery-A Prospective, Observational Cohort Study

Cardiac surgery and subsequent treatment in the intensive care unit (ICU) has been shown to be associated with functional decline, especially in elderly patients. Due to the different assessment tools and assessment periods, it remains yet unclear what parameters determine unfavorable outcomes. This study sought to identify risk factors during the entire perioperative period and focused on the decline in activity of daily living (ADL) half a year after cardiac surgery. Follow-ups of 125 patients were available. It was found that in the majority of patients (60%), the mean ADL declined by 4.9 points (95% CI, −6.4 to −3.5; p < 0.000). In the “No decline” -group, the ADL rose by 3.3 points (2.0 to 4.6; p < 0.001). A multiple regression analysis revealed that preoperative cognitive impairment (MMSE ≤ 26; Exp(B) 2.862 (95%CI, 1.192–6.872); p = 0.019) and duration of postoperative delirium ≥ 2 days (Exp(B) 3.534 (1.094–11.411); p = 0.035) was independently associated with ADL decline half a year after the operation and ICU. Of note, preoperative ADL per se was neither associated with baseline cognitive function nor a risk factor for functional decline. We conclude that the preoperative assessment of cognitive function, rather than functional assessments, should be part of risk stratification when planning complex cardiosurgical procedures.

Definiert das Alter den geriatrischen Patienten?

Ältere Menschen stellen einen wachsenden Anteil unserer täglich medizinisch und chirurgisch zu versorgenden Patienten dar. Allerdings definiert das kalendarische Alter alleine den älteren Patienten nur unzureichend. Vielmehr scheint das biologische Alter oder das Maß an Gebrechlichkeit entscheidend für die Charakterisierung zu sein. Auch der Prozentsatz der Menschen, die gebrechlich sind, ist in den letzten Jahrzehnten stetig gestiegen. Gebrechlichkeit oder Frailty ist ein geriatrisches Syndrom, welches durch verringerte physische und psychische Reserven zur Kompensation gekennzeichnet ist. Die beiden am häufigsten genutzten Ansätze zur Definition von Gebrechlichkeit sind der phänotypische Ansatz und der Ansatz der Defizitakkumulation. Für ältere Patienten haben sich in diesem Zusammenhang 2 Interventionspunkte in der klinischen Praxis herauskristallisiert: 1. die präinterventionelle/operative Identifizierung von Hochrisikopatienten, um sowohl die Patientenerwartungen als auch die chirurgische Entscheidungsfindung zu steuern, und 2. periinterventionelle/operative Optimierungsstrategien für gebrechliche Patienten. Noch fehlt ein mit vertretbarem Zeitaufwand in der klinischen Praxis umsetzbarer, objektiver Goldstandard zur Analyse der Frailty.

The importance of the Heart Team evaluation before transcatheter aortic valve replacement: Results from the BRAVO-3 trial

BACKGROUND/OBJECTIVES

Clinicians use validated scores to risk-stratify patients undergoing transcatheter aortic valve replacement (TAVR). However, evaluation by the Heart Team often deems patients to be at higher risk than their formal scores suggest. We sought to assess clinical outcomes of TAVR patients defined as high-risk by the Heart Team's assessment versus the patient's logistic EuroSCORE (LES).

METHODS

The BRAVO-3 trial randomized patients at high risk (LES ≥ 18, or deemed inoperable by the Heart Team) to TAVR with periprocedural anticoagulation with unfractionated heparin versus bivalirudin. Endpoints included net adverse cardiac events (NACE: the composite of all-cause mortality, MI, stroke, or bleeding), major adverse cardiovascular events (MACE: death, MI, or stroke), the individual components of MACE, major vascular complications, BARC ≥ 3b bleeding and VARC life-threatening bleeding at 30 days. We compared patients deemed high-risk based on LES ≥ 18 versus high-risk by the Heart Team despite lower LES.

RESULTS

A total of 467/800 (58.4%) patients were deemed high-risk by the Heart Team despite LES < 18. After multivariable analysis, there were no differences in the odds of endpoints between groups (NACE, OR_LES≥18 : 1.32, 95% CI 0.86-2.02, p = .21; MACE, OR_LES≥18 : 1.27, 95% CI 0.72-2.25, p = .41; major vascular complications, OR_LES≥18 : 0.97, 95% CI 0.65-1.44, p = .88; BARC ≥3b, OR_LES≥18 : 1.38, 95% CI 0.82-2.33, p = .23; and VARC life-threatening bleeding, OR_LES≥18 : 0.99, 95% CI 0.69-1.41, p = .95).

CONCLUSION

Patients undergoing TAVR and labeled high-risk by LES ≥ 18 or Heart Team assessment despite LES < 18 have comparable short-term outcomes. Assignment of high-risk status to over 50% of patients is attributable to Heart Team's clinical assessment.

Workshop on Synergies Between Alzheimer's Research and Clinical Gerontology and Geriatrics: Current Status and Future Directions

Age is the strongest risk factor for physical disability and Alzheimer's disease (AD) and related dementias. As such, other aging-related risk factors are also shared by these two health conditions. However, clinical geriatrics and gerontology research has included cognition and depression in models of physical disability, with less attention to the pathophysiology of neurodegenerative disease. Similarly, AD research generally incorporates limited, if any, measures of physical function and mobility, and therefore often fails to consider the relevance of functional limitations in neurodegeneration. Accumulating evidence suggests that common pathways lead to physical disability and cognitive impairment, which jointly contribute to the aging phenotype. Collaborations between researchers focusing on the brain or body will be critical to developing, refining, and testing research paradigms emerging from a better understanding of the aging process and the interacting pathways contributing to both physical and cognitive disability. The National Institute of Aging sponsored a workshop to bring together the Claude D. Pepper Older Americans Independence Center and AD Center programs to explore areas of synergies between the research concerns of the two programs. This article summarizes the proceedings of the workshop and presents key gaps and research priorities at the intersection of AD and clinical aging research identified by the workshop participants.

Frailty and Exercise Training: How to Provide Best Care after Cardiac Surgery or Intervention for Elder Patients with Valvular Heart Disease

The aim of this literature review was to evaluate existing evidence on exercise-based cardiac rehabilitation (CR) as a treatment option for elderly frail patients with valvular heart disease (VHD). Pubmed database was searched for articles between 1980 and January 2018. From 2623 articles screened, 61 on frailty and VHD and 12 on exercise-based training for patients with VHD were included in the analysis. We studied and described frailty assessment in this patient population. Studies reporting results of exercise training in patients after surgical/interventional VHD treatment were analyzed regarding contents and outcomes. The tools for frailty assessment included fried phenotype frailty index and its modifications, multidimensional geriatric assessment, clinical frailty scale, 5-meter walking test, serum albumin levels, and Katz index of activities of daily living. Frailty assessment in CR settings should be based on functional, objective tests and should have similar components as tools for risk assessment (mobility, muscle mass and strength, independence in daily living, cognitive functions, nutrition, and anxiety and depression evaluation). Participating in comprehensive exercise-based CR could improve short- and long-term outcomes (better quality of life, physical and functional capacity) in frail VHD patients. Such CR program should be led by cardiologist, and its content should include (1) exercise training (endurance and strength training to improve muscle mass, strength, balance, and coordination), (2) nutrition counseling, (3) occupational therapy (to improve independency and cognitive function), (4) psychological counseling to ensure psychosocial health, and (5) social worker counseling (to improve independency). Comprehensive CR could help to prevent, restore, and reduce the severity of frailty as well as to improve outcomes for frail VHD patients after surgery or intervention.

Frequency and Consequences of Cognitive Impairmentin Patients Underwent Transcatheter Aortic Valve Implantation

Cognitive impairment is common in patients underwent transcatheter aortic valve implantation (TAVI) and might affect procedure outcomes. This study evaluated the incidence of preprocedural cognitive impairment and its impact on clinical outcomes after TAVI. We analyzed the data of 1,111 patients (age ≥70 years) obtained from the Optimized CathEter vAlvular iNtervention (OCEAN-TAVI) registry. The cognitive performance of all patients was assessed using the Mini-Mental State Examination (MMSE) at baseline. We evaluated the 1-year cumulative mortality after TAVI according to the MMSE performance. Cognitive impairment was present in 420 (38%) of 1,111 patients. Compared with patients with normal cognition, those with cognitive impairment showed higher cumulative all-cause and noncardiovascular mortality rates at 1 year (14% vs. 8%, p = 0.001; 11% vs. 5%, p <0.001, respectively). Moreover, cognitive impairment increased the risk of mortality from sepsis (2% vs. 0.4%; hazard ratio, 4.2; 95% confidence interval, 1.3 to 13.5; p = 0.02). In adjusted models, cognitive impairment was an independent risk factor for 1-year all-cause mortality (adjusted hazard ratio, 2.1; 95% confidence interval, 1.1 to 4.0; p = 0.02). Although patients with cognitive impairment had more in-hospital adverse outcomes, including prolonged hospital stays, major bleeding and vascular complications, and acute kidney injury, than did those with normal cognition, the 30-day mortality was similar between the groups (1% in the two groups; p >0.99). In conclusion, cognitive impairment based on the MMSE score was an independent predictor of mortality at 1 year after TAVI.

Steps to Enhance Early Recovery After Hematopoietic Stem Cell Transplantation: Lessons Learned From a Physical Activity Feasibility Study

AIMS

This pilot study tested and refined a free-living physical activity intervention. The investigators evaluated the acceptability and feasibility of the intervention after hematopoietic stem cell transplantation and determined preliminary effects on physical activity, fatigue, muscle strength, functional ability, and quality of life.

DESIGN

This pilot study used a 1-group, pretest-posttest design.

METHODS

The free-living physical activity intervention consisted of an education component and 6 weeks of gradually increasing physical activity after discharge from the hospital. The intervention was designed to increase steps by 10% weekly. Subjects were assessed before transplantation and during the seventh week after discharge from the hospital after completing the intervention. Pretest-posttest scores were analyzed with paired t tests.

RESULTS

Subject wore the physical activity tracker for an average of 38 of 42 days and met their physical activity goals 57% of the time. Subjects reported significantly less physical fatigue after the free-living physical activity intervention compared with baseline (P = .05). Improvements in quality of life approached significance (P = .06).

CONCLUSION

The findings demonstrate that the free-living physical activity intervention implemented during the very early recovery period after transplantation is feasible and acceptable. The intervention potentially reduces fatigue and improves quality of life. The positive results must be interpreted cautiously given the pilot nature of the study. The evidence supports continued investigation.

Can a Left Ventricular Assist Device in Individuals with Advanced Systolic Heart Failure Improve or Reverse Frailty?

BACKGROUND/OBJECTIVES

Frailty, characterized by low physiological reserves, is strongly associated with vulnerability to adverse outcomes. Features of frailty overlap with those of advanced heart failure, making a distinction between them difficult. We sought to determine whether implantation of a left ventricular assist device (LVAD) would decrease frailty.

DESIGN

Prospective, cohort study.

SETTING

Five academic medical centers.

PARTICIPANTS

Frail individuals (N = 29; mean age 70.6 ± 5.5, 72.4% male).

MEASUREMENTS

Frailty, defined as having 3 or more of the Fried frailty criteria, was assessed before LVAD implantation and 1, 3, and 6 months after implantation. Other domains assessed included quality of life, using the Kansas City Cardiomyopathy Questionnaire; mood, using the Patient Health Questionnaire; and cognitive function, using the Trail-Making Test Part B.

RESULTS

After 6 months, three subjects had died, and one had undergone a heart transplant; of 19 subjects with serial frailty measures, the average number of frailty criteria decreased from 3.9 ± 0.9 at baseline to 2.8 ± 1.4 at 6 months (P = .003). Improvements were observed after 3 to 6 months of LVAD support, although 10 (52.6%) participants still had 3 or more Fried criteria, and all subjects had at least one at 6 months. Changes in frailty were associated with improvement in QOL but not with changes in mood or cognition. Higher estimated glomerular filtration rate at baseline was independently associated with a decrease in frailty.

CONCLUSION

Frailty decreased in approximately half of older adults with advanced heart failure after 6 months of LVAD support. Strategies to enhance frailty reversal in this population are worthy of additional study.

The impact of frailty on mortality after transcatheter aortic valve replacement

Frailty is a notably common problem in patients with severe aortic stenosis (AS) undergoing transcatheter aortic valve replacement (TAVR) evaluation. Studies have demonstrated significant associations between frailty and worse outcomes in patients undergoing TAVR including higher risks of disability and mortality and admissions to long-term care facility. While there are multiple methods to identify and measure frailty, there is a critical need for a precise definition of frailty and its standardized assessment protocol based on well-established tests covering all aspects of the frailty, as a syndrome. Incorporation of the available frailty evaluation into pre-operative risk assessments chances of morbidity or mortality following surgery can help enhancing performance and improve shared decision-making between physicians and their patients. In this review, we present the perspectives of the impact of frailty on mortality in patients undergoing TAVR.

Impact of frailty on mortality after transcatheter aortic valve implantation

BACKGROUND

We sought to investigate the relation between frailty indices and 12-month mortality after transcatheter aortic valve implantation (TAVI).

METHODS

We included 101 consecutive patients with severe aortic stenosis who have undergone TAVI. Frailty indices according to Valve Academic Research Consortium-2 recommendations (5-m walk test [5MWT] and hand grip strength) as well as other available scales of frailty (Katz index, Elderly Mobility Scale [EMS], Canadian Study of Health and Aging [CSHA] scale, Identification of Seniors at Risk [ISAR] scale) were assessed at baseline. The primary endpoint was 12-month all-cause mortality.

RESULTS

Twelve-month all-cause mortality was 17.8%. According to 5MWT, 17.8% were frail; hand grip test: 6.9%; Katz index: 17.8%; EMS: 7.9%; CSHA scale: 16.9%; and ISAR scale: 52.5%. Associations between frailty indices and 12-month all-cause mortality after TAVI were significant in Cox regression analysis (frail vs not frail, presented as hazard ratio[95%CI] adjusted for logistic EuroSCORE): for 5MWT, 72.38 (15.95-328.44); for EMS, 23.39 (6.89-79.34); for CSHA scale, 53.97 (14.67-198.53); for Katz index, 21.69 (6.89-68.25); for hand grip strength, 51.54 (12.98-204.74); and for ISAR scale, 15.94 (2.10-120.74). Similarly, such relationship was confirmed when 5MWT, EMS, and CSHA were used as continuous variables (hazard ratio [95%CI] adjusted for logistic EuroSCORE: for 5MWT per 1-second increase, 2.55 [1.94-3.37]; for EMS per 1-point decrease, 2.90 (1.99-4.21); and for CSHA per 1-point increase, 3.13 [2.17-4.53]).

CONCLUSIONS

Our study confirmed a strong predictive ability of most of the proposed frailty indices for 12-month mortality after TAVI. For patients scheduled for TAVI, the use of frailty indices, which are easy and quick to assess on clinical basis but with strong performance, for example, 5MWT, EMS, or hand grip test, may be advocated.

Strength Training to Enhance Early Recovery after Hematopoietic Stem Cell Transplantation

Intensive cancer treatment followed by hematopoietic stem cell transplantation (HCT) results in moderate to severe fatigue and physical inactivity, leading to diminished functional ability. The purpose of this study was to determine the efficacy of an exercise intervention, strength training to enhance early recovery (STEER), on physical activity, fatigue, muscle strength, functional ability, and quality of life after HCT. This single-blind, randomized clinical trial compared strength training (n = 33) to usual care plus attention control with health education (UC + AC with HE) (n = 34). Subjects were stratified by type of transplantation and age. STEER consisted of a comprehensive program of progressive resistance introduced during hospitalization and continued for 6 weeks after hospital discharge. Fatigue, physical activity, muscle strength, functional ability, and quality of life were assessed before HCT hospital admission and after intervention completion. Data were analyzed using split-plot analysis of variance. Significant time × group interactions effects were noted for fatigue (P = .04). The STEER group reported improvement in fatigue from baseline to after intervention whereas the UC + AC with HE group reported worsened fatigue from baseline to after intervention. Time (P < .001) and group effects (P = .05) were observed for physical activity. Physical activity declined from baseline to 6 weeks after hospitalization. The STEER group was more physically active. Functional ability tests (timed stair climb and timed up and go) resulted in a significant interaction effect (P = .03 and P = .05, respectively). Subjects in the UC + AC with HE group were significantly slower on both tests baseline to after intervention, whereas the STEER group's time remained stable. The STEER group completed both tests faster than the UC + AC with HE group after intervention. Study findings support the use of STEER after intensive cancer treatment and HCT. Strength training demonstrated positive effects on fatigue, physical activity, muscle strength, and functional ability. The exact recovery patterns between groups and over time varied; the STEER group either improved or maintained their status from baseline to after intervention (6 weeks after hospital discharge) whereas the health education group generally declined over time or did not change.

Physical frailty in older people with severe aortic stenosis

BACKGROUND

Assessment of physical frailty is important among elderly with severe aortic stenosis (AS) when considering treatment.

AIMS

We aimed to: (1) investigate the prevalence of physical frailty in older people with severe AS and (2) examine factors related to physical frailty.

METHODS

A total of 125 consecutive elderly AS patients (mean age 84.6 ± 4.4 year) were enrolled. Physical frailty was defined as scoring ≤8 points on the short physical performance battery (SPPB). Factors likely related to physical frailty, including cardiac function, nutritional and metabolic status, kidney function, medical history, and comorbidities, were evaluated. Logistic regression analyses were used to examine which factors were related to physical frailty.

RESULTS

Physical frailty was prevalent in 38.4 %. After sex and age adjusted, the following were significantly related to physical frailty: LVEF (adjusted OR per 10 % decrease: 1.39, p < 0.05), the Mini Nutritional Assessment-Short Form (adjusted OR per 1 point decrease: 1.21, p < 0.05), serum albumin (adjusted OR per 1 g/dL decrease: 2.64, p < 0.05), HDL-C (adjusted OR per 10 mg/dL decrease: 1.52, p < 0.01), eGFR (adjusted OR per 10 mL/min decrease: 1.59, p < 0.05), grip strength (adjusted OR per 10 kg decrease: 3.60, p < 0.01), coronary heart disease (adjusted OR: 2.78, p < 0.01), cerebrovascular disease (adjusted OR: 6.06, p < 0.01), and musculoskeletal disorders (adjusted OR: 3.28, p < 0.01).

CONCLUSIONS

The prevalence of physical frailty is high and related to nutritional status, comorbidities, and cardiac status.

[Aortic valve replacement in the elderly]

The treatment of severe symptomatic aortic valve stenosis by conventional aortic valve replacement (AVR) or by transcatheter aortic valve implantation (TAVI) has a good perinterventional prognosis even for patients of advanced age. Having a heart team select the best management strategies based on current guidelines for each individual patient is essential for success. Especially in elderly and increasingly multimorbid patients with sometimes severe preconditions, the detection of functional deficits is relevant not only for the mortality but also for perioperative and postoperative complications as well as the functional outcome. Various methods of geriatric assessment are important supplements to standard risk scores. The aim is to implement targeted interventions to minimize the risk factors and to improve the prognosis for elderly patients. The aim of this article is to provide an overview of the current therapy options for aortic valve replacement and to summarize current aspects of treatment options for elderly patients.

[Non-cardiac aspects of aortic stenosis in the elderly: A review]

Aortic stenosis (AS) is the most frequent valve disease in the elderly population Treatment is valve replacement either by open surgery, or in the case of patients at high surgical risk, by TAVI (Transcatheter Aortic Valve Implantation). However, almost 40% of patients who have undergone TAVI show poor health outcomes, either due to death or because their clinical status does not improved. This review examines the non-cardiac aspects of patients with AS, which may help answer three key questions in order to evaluate this condition pre-surgically: 1) Are the symptoms presented by the patient exclusively explained by the AS, or are there other factors or comorbidities that could justify or increase them?, 2) What possibilities for improvement of health status and quality of life has the patient after the valve replacement?, and 3) How can we reduce the risk of a futile valve replacement?

Usefulness of Psoas Muscle Area to Predict Mortality in Patients Undergoing Transcatheter Aortic Valve Replacement

Frailty has become high-priority theme in cardiovascular diseases because of aging and increasingly complex nature of patients. Low muscle mass is characteristic of frailty, in which invasive interventions are avoided if possible because of decreased physiological reserve. This study aimed to determine if the psoas muscle area (PMA) could predict mortality and to investigate its utility in patients who underwent transcatheter aortic valve replacement (TAVR). We retrospectively reviewed 232 consecutive patients who underwent TAVR. Cross-sectional areas of the psoas muscles at the level of fourth lumbar vertebra were measured by computed tomography and normalized to body surface area. Patients were divided into tertiles according to the normalized PMA for each gender (men: tertile 1, 1,708 to 1,178 mm(2)/m(2); tertile 2, 1,176 to 1,011 mm(2)/m(2); and tertile 3, 1,009 to 587 mm(2)/m(2); women: tertile 1, 1,436 to 962 mm(2)/m(2); tertile 2, 952 to 807 mm(2)/m(2); and tertile 3, 806 to 527 mm(2)/m(2)). Smaller normalized PMA was independently correlated with women and higher New York Heart Association classification. After adjustment for multiple confounding factors, the normalized PMA tertile was independently associated with mortality at 6 months (adjusted hazard ratio 1.53, 95% confidence interval 1.06 to 2.21). Kaplan-Meier analysis showed that tertile 3 had higher mortality rates than tertile 1 at 6 months (14% and 31%, respectively, p = 0.029). Receiver-operating characteristic analysis showed that normalized PMA provided the increase of C-statistics for predicting mortality for a clinical model and gait speed. In conclusion, PMA is an independent predictor of mortality after TAVR and can complement a clinical model and gait speed.

Frailty Trajectories After Treatment for Coronary Artery Disease in Older Patients

BACKGROUND

Frailty is an independent risk factor for cardiovascular outcomes. However, its trajectory after coronary artery disease treatment is unknown.

METHODS AND RESULTS

Three hundred seventy-four patients undergoing nonemergent cardiac catheterization followed by treatment (ie, 128 coronary artery bypass graft [CABG], 150 percutaneous coronary intervention [PCI], 96 medical therapy only) were observed for 30 months. A frailty index (FI) score was calculated at baseline (before initial treatment) and 6, 12, and 30 months after treatment. Random-effects models compared FI score trajectories by sex, age, and treatment group. Mean baseline FI scores were 0.170, 0.154, and 0.154 for CABG, PCI, and medical therapy only, respectively. FI scores decreased (improved) 6 months after initial treatment, then increased (worsened) at 12 and 30 months (P<0.001 for differences over time). Women had nonsignificantly higher FI scores than men (P=0.097) but followed the same trajectory (P=0.352 for differences over time). In patients aged ≥75 years, FI scores increased postbaseline for CABG and medical therapy only and after 6 months for PCI patients. Patients <75 years assigned to PCI and CABG experienced a sustained frailty reduction, whereas those assigned to medical therapy only showed stable frailty over the 30-month follow-up period (P value for differences over time by age and treatment group=0.041).

CONCLUSIONS

With coronary artery disease treatment, frailty generally follows a U-shaped trajectory, but the pattern may differ by age and treatment. Further investigation is needed to confirm these observations and determine whether patients might benefit from consideration of frailty status.

Relationship Between Accelerometer-Measured Activity and Self-Reported or Performance-Based Function in Older Adults with Severe Aortic Stenosis

In older adults with aortic stenosis, we evaluated whether accelerometer-measured physical activity provides distinct clinical information apart from self-reported surveys or performance-based function tests. We employed wrist-mounted accelerometry in 52 subjects with severe aortic stenosis prior to transcatheter aortic valve replacement (TAVR). Daily daytime activity was estimated using the maximum 10 h of daily accelerometer-measured activity (M10) reported in activity counts. Subjects completed baseline surveys (New York Heart Association (NYHA), Short Form 12 (SF12), Kansas City Cardiomyopathy Questionnaire (KCCQ), EuroQol-5D (EQ-5D), Revised Life Orientation Test (LOT-R), Life Space, Detailed Activity Form) and performance-based function tests (Short Physical Performance Battery, 6-min walk test distance, grip strength) to estimate functional status. Simple and multiple linear regression models were used to evaluate the relationship between accelerometer-measured activity and survey data and performance-based function tests. Among all baseline surveys and performance-based function tests, the only statistically significant univariable relationships identified were weak, negative associations between M10 and SF-12 Mental Composite Score (R²=0.1970, P=0.04) and between M10 and grip strength (R²=0.1568, P=0.004). Neither multiple linear regression of overall survey data (R²=0.6159, P=0.23) nor performance-based function tests (R²=0.1743, P=0.10) correlated with M10. Self-reported surveys and performance-based function tests are not meaningfully correlated with daytime accelerometer-measured activity. The results of our study suggest that accelerometer-measured physical activity provides distinct clinical information apart from self-reported surveys or performance-based function tests.

Impact of frailty on outcomes after percutaneous coronary intervention: a prospective cohort study

Background

Average life expectancy is rising, resulting in increasing numbers of elderly, frail individuals presenting with coronary artery disease and requiring percutaneous coronary intervention (PCI). PCI can be of value for this population, but little is known about the balance of benefit versus risk, particularly in the frail.

Objective

To determine the relationship between frailty and clinical outcomes in patients undergoing PCI.

Methods

Patients undergoing PCI, for either stable angina or acute coronary syndrome, were prospectively assessed for frailty using the Canadian Study of Health and Ageing Clinical Frailty Scale. Demographics, clinical and angiographic data were extracted from the hospital database. Mortality was obtained from the Office of National Statistics.

Results

Frailty was assessed in 745 patients undergoing PCI. The mean age of patients was 62±12 years and 70% were males. The median frailty score was 3 (IQR 2–4). A frailty score ≥5, indicating significant frailty, was present in 81 (11%) patients. Frail patients required longer hospitalisation after PCI. Frailty was also associated with increased 30-day (HR 4.8, 95% CI 1.4 to 16.3, p=0.013) and 1 year mortality (HR 5.9, 95% CI 2.5 to 13.8, p<0.001). Frailty was a predictor of length of hospital stay and mortality, independent of age, gender and comorbidities.

Conclusions

A simple assessment of frailty can help predict mortality and the length of hospital stay, and may therefore guide healthcare providers to plan PCI and appropriate resources for frail patients.

Frailty in NHANES: Comparing the frailty index and phenotype

The two most commonly employed frailty measures are the frailty phenotype and the frailty index. We compared them to examine whether they demonstrated common characteristics of frailty scales, and to examine their association with adverse health measures including disability, self-reported health, and healthcare utilization. The study examined adults aged 50+ (n=4096) from a sequential, cross-sectional sample (2003-2004; 2005-2006), National Health and Nutrition Examination Survey. The frailty phenotype was modified from a previously adapted version and a 46-item frailty index was created following a standard protocol. Both measures demonstrated a right-skewed distribution, higher levels of frailty in women, exponential increase with age and associations with high healthcare utilization and poor self-reported health. More people classified as frail by the modified phenotype had ADL disability (97.8%) compared with the frailty index (56.6%) and similarly for IADL disability (95% vs. 85.6%). The prevalence of frailty was 3.6% using the modified frailty phenotype and 34% using the frailty index. Frailty index scores in those who were classified as robust by the modified phenotype were still significantly associated with poor self-reported health and high healthcare utilization. The frailty index and the modified frailty phenotype each confirmed previously established characteristics of frailty scales. The agreement between frailty and disability was high with each measure, suggesting that frailty is not simply a pre-disability stage. Overall, the frailty index classified more people as frail, and suggested that it may have the ability to discriminate better at the lower to middle end of the frailty continuum.

New frontiers in aortic therapy: focus on current trials and devices in transcatheter aortic valve replacement

The first decade of clinical experience with transcatheter aortic valve replacement since 2002 saw the development of 2 main valve systems, namely the Edwards Sapien balloon-expandable valve series and the Medtronic self-expanding CoreValve. These 2 valve platforms now have achieved commercial approval and application worldwide in patients with severe aortic stenosis whose perioperative risk for surgical intervention is high or extreme. In the second decade of transcatheter aortic valve replacement, clinical experience and refinements in valve design have resulted in clinical drift towards lower patient risk cohorts. There are currently 2 major trials, PARTNER II and SURTAVI, that are both evaluating the role of transcatheter aortic valve replacement in intermediate-risk patient cohorts. The results from these landmark trials may usher in a new clinical paradigm for transcatheter aortic valve replacement in its second decade.

Exploring changes in functional status while waiting for transcatheter aortic valve implantation

BACKGROUND

Aortic stenosis (AS) is a structural heart disease primarily associated with ageing. For people with multiple co-morbidities, surgical treatment may not be a safe or feasible option. Transcatheter aortic valve implantation (TAVI) is indicated for patients with symptomatic AS who are at excessive risk for surgical valve replacement and are likely to derive significant benefit. Functional status can deteriorate during the time between referral and procedure because of the rapid disease progression of severe AS and varying wait-times for treatment in Canada.

AIMS

The purpose of this study was to examine changes in functional status between time of eligibility assessment and TAVI procedure date.

METHODS

An exploratory prospective cohort study was conducted to evaluate changes in functional status including gait speed, frailty scores and cognitive status.

RESULTS

Thirty-two patients participated in the study with median age 81 years. Functional status declined between time of eligibility assessment and time of TAVI: gait speed increased by an average of 0.53 s (standard deviation (SD)=1.0, p=0.01) and frailty scores increased by an average of 0.31 (SD=0.64, p=0.01). Patients waiting longer than six weeks for TAVI had a larger decline in gait speed than patients waiting less than six weeks (p=0.02). Patients living alone had a larger increase in frailty scores compared to patients living with another adult (p=0.05).

CONCLUSION

Older adults with life-limiting AS are vulnerable to changes in functional status. In the absence of TAVI wait-time benchmarks, findings may be used to facilitate individualized care and management strategies and inform health-care policy.

Assessing the risk of aortic valve replacement for severe aortic stenosis in the transcatheter valve era

Surgical aortic valve replacement had been the only definitive treatment of severe aortic stenosis before the availability of transcatheter valve technology. Historically, many patients with severe aortic stenosis had not been offered surgery, largely related to professional and patient perception regarding the risks of operation relative to anticipated benefits. Such patients have been labeled as "high risk" or "inoperable" with respect to their suitability for surgery. The availability of transcatheter aortic valve replacement affords a new treatment option for patients previously not felt to be optimal candidates for surgical valve replacement and allows for the opportunity to reexamine the methods for assessing operative risk in the context of more than 1 available treatment. Standardized risk assessment can be challenging because of both the imprecision of current risk scoring methods and the variability in ascertaining risk related to operator experience as well as local factors and practice patterns at treating facilities. Operative risk in actuality is not an absolute but represents a spectrum from very low to extreme, and the conventional labels of high risk and inoperable are incomplete with respect to their utility in clinical decision making. Moving forward, the emphasis should be on developing an individual assessment that takes into account procedure risk as well as long-term outcomes evaluated in a multidisciplinary fashion, and incorporating patient preferences and goals in a model of shared decision making.

Patient evaluation and selection for transcatheter aortic valve replacement: the heart team approach

Transcatheter aortic valve replacement (TAVR) has been shown to significantly impact mortality and quality of life in patients with severe aortic stenosis (AS) who are deemed high risk for surgical aortic valve replacement (SAVR). Essential to these outcomes is proper patient selection. The multidisciplinary TAVR heart team was created to provide comprehensive patient evaluation and aid in proper selection. This review with outline the history and components of the heart team, and delineate the team's role in risk and frailty assessment, evaluation of common co-morbidities that impact outcomes, and the complex multi-modality imaging necessary for procedural planning and patient selection. The heart team is critical in determining patient eligibility and benefit and the optimal operative approach for TAVR. The future of structural heart disease will certainly require a team approach, and the TAVR heart team will serve as the successful model.

Integrating a palliative approach in a transcatheter heart valve program: bridging innovations in the management of severe aortic stenosis and best end-of-life practice

Severe aortic stenosis (AS) is the most prevalent structural heart disease and affects primarily older adults in their last decade of life. If the risk for surgery is high, transcatheter aortic valve implantation (TAVI) is the treatment of choice for many patients with suitable anatomy who are likely to derive significant benefit from this innovative and minimally invasive approach. In a large transcatheter heart valve (THV) centre that offers TAVI as one of the treatment options, of 565 consecutive referrals for the assessment of eligibility for TAVI over 18 months, 78 (14%) were deemed unsuitable candidates for TAVI or higher risk surgery by the interdisciplinary Heart Team because of their advanced disease, excessive frailty or comorbid burden. Concerns were raised for patients for whom TAVI is not an option. The integration of a palliative approach in a THV program offers opportunities to adopt best end-of-life practices while promoting innovative approaches for treatment. An integrated palliative approach to care focuses on meeting a patient's full range of physical, psychosocial and spiritual needs at all stages of a life-limiting illness, and is well suited for the severe AS and TAVI population. A series of interventions that reflect best practices and current evidence were adopted in collaboration with the Palliative Care Team and are currently under evaluation in a large TAVI centre. Changes include the introduction of a palliative approach in patient assessment and education, the measurement of symptoms, improved clarity about responsibility for communication and follow-up, and triggering referrals to palliative care services.

Frailty assessment in the cardiovascular care of older adults

Due to the aging and increasingly complex nature of our patients, frailty has become a high-priority theme in cardiovascular medicine. Despite the recognition of frailty as a pivotal element in the evaluation of older adults with cardiovascular disease (CVD), there has yet to be a road map to facilitate its adoption in routine clinical practice. Thus, we sought to synthesize the existing body of evidence and offer a perspective on how to integrate frailty into clinical practice. Frailty is a biological syndrome that reflects a state of decreased physiological reserve and vulnerability to stressors. Upward of 20 frailty assessment tools have been developed, with most tools revolving around the core phenotypic domains of frailty-slow walking speed, weakness, inactivity, exhaustion, and shrinking-as measured by physical performance tests and questionnaires. The prevalence of frailty ranges from 10% to 60%, depending on the CVD burden, as well as the tool and cutoff chosen to define frailty. Epidemiological studies have consistently demonstrated that frailty carries a relative risk of >2 for mortality and morbidity across a spectrum of stable CVD, acute coronary syndromes, heart failure, and surgical and transcatheter interventions. Frailty contributes valuable prognostic insights incremental to existing risk models and assists clinicians in defining optimal care pathways for their patients. Interventions designed to improve outcomes in frail elders with CVD such as multidisciplinary cardiac rehabilitation are being actively tested. Ultimately, frailty should not be viewed as a reason to withhold care but rather as a means of delivering it in a more patient-centered fashion.

The repeatability of gait speed and physiological cost index measurements in working adults

OBJECTIVES

To determine the performance characteristics of gait speed measurements and the physiological cost index (PCI; heart rate change/gait speed) in working adults.

METHODS

Gait speeds, heart rate changes, and non-steady state PCIs were calculated in 61 volunteers who worked in our health sciences center. These subjects completed 9 separate 100-foot walk tests in 3 separate sessions.

RESULTS

The mean heart rate change after a 100-foot walk was 16.6 ± 8.1 beats per minute. The mean gait speed was 76.1 ± 9.6 meters per minute, and the mean PCI was 0.22 ± 0.11 beats per meter. There were highly significant correlations among all measurements on the 9 separate tests (correlation coefficients 0.41-0.95); gait speed measurements had the highest correlations (0.91-0.95). In a multivariable model hypertension and arthritis were associated with reduced gait speeds.

CONCLUSION

Gait speed, heart rate changes, and non-steady state PCIs have good repeatability when measured over short walks. This information provides a rapid physiological assessment and a method for measuring changes in functional status in healthy subjects and most patients.

Utilization of a 5-Meter Walk Test in Evaluating Self-selected Gait Speed during Preoperative Screening of Patients Scheduled for Cardiac Surgery

PURPOSE

The 5-Meter Walk Test (5MWT) has been recommended for use by the Society of Thoracic Surgeons as an outcome measure in the Adult Cardiac Surgery Database to predict frailty in individuals who are candidates for cardiac surgery. However, there are no published reports of performance on this test in the literature. Therefore, the purpose of this study was to provide descriptive analysis of the 5MWT for individuals who were candidates for cardiac surgery.

METHODS

Retrospective analysis of 113 preoperative cardiac surgery candidates who underwent a 5MWT. Gait speed calculated from the test was completed as part of preoperative testing administered by physical therapists. Three trials were performed with up to a one minute rest between trials. Differences by trial, gender, use of assistive device, and gait or postural deviations were determined using t-tests.

RESULTS

Mean gait speed was 1.05 (SD 0.26) m/s for the subjects. There was a statistically significant increase in gait speed from trial 1 to trial 3 by 0.05 (0.08) m/s (p < 0.0001). There were no significant differences in gait speed between males and females. Participants using assistive devices displayed a significantly slower mean gait speed of 0.70 (0.27) than those who walked unaided, with a mean gait speed of 1.08 (0.24) m/s (p < 0.0001). Participants with noted gait or postural deviations also walked significantly slower (mean 0.84, SD 0.22) than those without deviations (mean 1.15, SD 0.21) (p < 0.0001).

CONCLUSIONS

Subjects displayed a slight increase in speed from trial 1 to trial 3, reinforcing a cited benefit of the shorter distance of the 5MWT that may limit fatigue. Although statistically significant, the increase in speed from trial 1 to 3 may not be clinically significant in relation to the intent of the test. Significantly slower gait speeds were noted when a subject had an observable gait or postural deviation or used an assistive device.

Relation between six-minute walk test performance and outcomes after transcatheter aortic valve implantation (from the PARTNER trial)

Functional capacity as assessed by 6-minute walk test distance (6MWTD) has been shown to predict outcomes in selected cohorts with cardiovascular disease. To evaluate the association between 6MWTD and outcomes after transcatheter aortic valve implantation (TAVI) among participants in the Placement of AoRTic TraNscathetER valve (PARTNER) trial, TAVI recipients (n = 484) were stratified into 3 groups according to baseline 6MWTD: unable to walk (n = 218), slow walkers (n = 133), in whom 6MWTD was below the median (128.5 meters), and fast walkers (n = 133) with 6MWTD >128.5 meters. After TAVI, among fast walkers, follow-up 6MWTD decreased by 44 ± 148 meters at 12 months (p <0.02 compared with baseline). In contrast, among slow walkers, 6MWTD improved after TAVI by 58 ± 126 meters (p <0.001 compared with baseline). Similarly, among those unable to walk, 6MWTD distance increased by 66 ± 109 meters (p <0.001 compared with baseline). There were no differences in 30-day outcomes among 6MWTD groups. At 2 years, the rate of death from any cause was 42.5% in those unable to walk, 31.2% in slow walkers, and 28.8% in fast walkers (p = 0.02), driven primarily by differences in noncardiac death. In conclusion, among high-risk older adults undergoing TAVI, baseline 6MWTD does not predict procedural outcomes but does predict long-term mortality. Nonetheless, patients with poor baseline functional status exhibit the greatest improvement in 6MWTD. Additional work is required to identify those with poor functional status who stand to benefit the most from TAVI.