Frailty in advanced heart failure: a systematic review

The Relationship Between Rehabilitation and Frailty in Advanced Heart or Lung Disease

Background

Frailty increases morbidity and mortality in patients with advanced heart and lung disease. Emerging evidence shows that postoperative cardiac or pulmonary rehabilitation can improve the frailty status of these patients. The aim of this hypothesis-generating study was to test the relationship between prehabilitation and frailty in patients with advanced heart or lung disease referred for heart and lung transplantation.

Methods

The study was a retrospective audit of consecutive patients with advanced heart or lung disease referred for transplant assessment between January 2021 and December 2022. Frailty scores were recorded using Fried's frailty phenotype (range, 0-5), and rehabilitation status of patients at the time of frailty assessment was recorded.

Results

Of 286 patients, 124 patients had advanced heart disease (mean age 53 ± 12 y; 82% men) and 162 patients had advanced lung disease (mean age 55 ± 12 y; 43% men). Sixty-nine (24%) patients were robust (score 0), 156 (55%) were prefrail (score, 1-2), and 61 (21%) were frail (score, 3-5). Eighty-two (29%) patients participated in hospital-based rehabilitation, 72 (25%) in home-based rehabilitation, and 132 (46%) in no rehabilitation. Frailty scores were significantly lower in patients participating in hospital-based or home-based rehabilitation compared with patients not participating in rehabilitation (0.8 ± 1.0 versus 0.8 ± 0.9 versus 2.3±1.2, P < 0.0001).

Conclusions

This study shows that patients participating in cardiac or pulmonary rehabilitation are less frail compared with patients not participating in rehabilitation. These findings suggest that prehabilitation could be beneficial for patients awaiting heart or lung transplantation.

Impact of Frailty on Left Ventricular Assist Device Clinical Outcomes

Frailty is a clinical syndrome prevalent in older adults and carries poor outcomes in patients with heart failure. We investigated the impact of frailty on left ventricular assist device (LVAD) clinical outcomes. The Nationwide Readmission Database was used to retrospectively identify patients with a primary diagnosis of heart failure who underwent LVAD implantation during their hospitalization from 2014 to 2020. Patients were categorized into frail and nonfrail groups using the Hospital Frailty Risk Score. Cox and logistic regression were used to predict the impact of frailty on inpatient mortality, 30-day readmissions, length of stay, and discharge to a skilled nursing facility. LVADs were implanted in 11,465 patients who met the inclusion criteria. There was more LVAD use in patients who were identified as frail (81.6% vs 18.4%, p <0.001). The Cox regression analyses revealed that LVAD insertion was not associated with increased inpatient mortality in frail patients (hazard ratio 1.15, 95% confidence interval 0.81 to 1.65, p = 0.427). Frail patients also did not experience a higher likelihood of readmissions within 30 days (hazard ratio 1.15, 95% confidence interval 0.91 to 1.44, p = 0.239). LVAD implantation did not result in a significant increase in inpatient mortality or readmission rates in frail patients compared with nonfrail patients. These data support continued LVAD use in this high-risk patient population.

Which frailty tool best predicts morbidity and mortality in ambulatory patients with heart failure? A prospective study

BACKGROUND

Frailty is common in patients with heart failure (HF) and is associated with adverse outcome, but it is uncertain how frailty should best be measured.

OBJECTIVES

To compare the prognostic value of commonly-used frailty tools in ambulatory patients with HF.

METHODS AND RESULTS

We assessed, simultaneously, three screening tools [clinical frailty scale (CFS); Derby frailty index (DFI); acute frailty network (AFN) frailty criteria), three assessment tools (Fried criteria; Edmonton frailty score (EFS); deficit index (DI)) and three physical tests (handgrip strength, timed get-up-and-go test (TUGT), 5-metre walk test (5MWT)] in consecutive patients with HF attending a routine follow-up visit. 467 patients (67% male, median age = 76 years, median NT-proBNP = 1156 ng/L) were enrolled. During a median follow-up of 554 days, 82 (18%) patients died and 201 (43%) patients were either hospitalised or died. In models corrected for age, Charlson score, haemoglobin, renal function, sodium, NYHA, atrial fibrillation (AF), and body mass index, only log[NT-proBNP] and frailty were independently associated with all-cause death. A base model for predicting mortality at 1 year including NYHA, log[NT-proBNP], sodium and AF, had a C-statistic = 0.75. Amongst screening tools: CFS (C-statistic = 0.84); amongst assessment tools: DI (C-statistic = 0.83) and amongst physical test: 5MWT (C-statistic = 0.80), increased model performance most compared with base model (P <0.05 for all).

CONCLUSION

Frailty is strongly associated with adverse outcomes in ambulatory patients with HF. When added to a base model for predicting mortality at 1 year including NYHA, NT-proBNP, sodium, and AF, CFS provides comparable prognostic information with assessment tools taking longer to perform.

Fast systematic geriatric assessment in acute heart failure patients admitted in Cardiology

BACKGROUND

Heart failure prevalence is increasing in elder adults. These patients usually present geriatric syndromes, especially frailty. The effect of frailty on heart failure is under discussion but there are few data about the clinical characterization of frail patients who are admitted for acute heart failure decompensation.

OBJECTIVE

The purpose of this study was to study the differences in clinical baseline variables and geriatric scales between frail and non-frail patients admitted to the Cardiology unit via the Emergency Department for acute heart failure.

METHODS

We enrolled all patients with acute heart failure who were admitted to the Cardiology unit from the Emergency Department of our hospital from July 2020 through May 2021. A multidimensional and comprehensive geriatric assessment was performed at the moment of admission. We studied differences in baseline variables and geriatric scales according to the frailty status determined by the FRAIL scale.

RESULTS

A total of 202 patients were included. In the whole population, 68 (33.7%) patients presented frailty defined by a FRAIL score ≥ 3. The frail patients were older (80±9 vs. 69±12 years; p<0.001), and had a worse quality of life (58.31±12.18 vs.39.26±13.71 points; p<0.001) according to the Minnesota scale, presented high comorbidity (47 (69.1%) vs. 67 (50.4%) patients; p = 0.011) defined as ≥3 points according to the Charlson scale and were more dependent (40 (58.8%) vs. 25 (18.8%) patients; p<0.001) according to the Barthel scale. The frail patients presented higher MAGGIC risk scores (24.09±4.99 vs. 18.89±6.26; p<0.001). Despite this adverse profile, the treatments prescribed during the admission and at the hospital discharge were similar.

CONCLUSIONS

The prevalence of geriatric syndromes, especially frailty, is very high in patients admitted for acute heart failure. Frail patients with acute heart failure had an adverse clinical profile with more prevalence of concomitant geriatric syndromes. Therefore, we consider that a geriatric assessment should be performed during the admission of acute heart failure patients to improve care and attention.

Impact of Fried Frailty Phenotype on Postoperative Outcomes After Durable Contemporary Mechanical Circulatory Support: A Single-Center Experience

Background

Frailty is prevalent in advanced heart failure patients and may help distinguish patients at risk of worse outcomes. However, the effect of frailty on postoperative clinical outcomes is still understudied. Therefore, we aim to study the relationship between frailty and postoperative clinical outcomes in patients undergoing long-term mechanical circulatory support (MCS).

Methods

Forty-six patients undergoing durable MCS (left ventricular assist device and total artificial heart) placement at our medical center were assessed for frailty pre-implant. Frailty was defined as ≥ 3 physical components of the Fried frailty phenotype. Our primary endpoint is 1 year of survival post-implant. Secondary endpoints include 30-day all-cause rehospitalization, pump thrombosis, neurological event (stroke/transient ischemic attack), gastrointestinal bleeding, and driveline infection within 12 months post-MCS support.

Results

Of the 46 patients, 32 (69%) met the criteria for frailty according to Fried. The cohort's median age was 67.0 years. The frail group had statistically significant lower left ventricular ejection fraction (LVEF) (11% vs. 20%, P = 0.017) and lower albumin (3.5 vs. 4.0 g/dL, P = 0.021). The frail cohort also had significantly higher rates of comorbid chronic kidney disease (47% vs. 7%, P = 0.016). There were no differences between the frail vs. non-frail group in terms of 30-day readmission rates (40% vs. 39%, P = 0.927) and 1-year post-intervention survival (log-rank, P = 0.165). None of the other secondary endpoints reached statistical significance, although the incidence of gastrointestinal bleed (24% vs. 16%, P = 0.689) and pump thrombosis (8% vs. 0%, P = 0.538) were higher in the frail group.

Conclusions

Preoperative Fried frailty was not associated with readmission at 30 days, mortality at 365 days, and other postoperative outcomes in long-term durable MCS patients. Findings may need further validation in larger studies.

Frailty and solid-organ transplant candidates: a scoping review

Background

There is currently no consensus as to a standardized tool for frailty measurement in any patient population. In the solid-organ transplantation population, routinely identifying and quantifying frailty in potential transplant candidates would support patients and the multidisciplinary team to make well-informed, individualized, management decisions. The aim of this scoping review was to synthesise the literature regarding frailty measurement in solid-organ transplant (SOT) candidates.

Methods

A search of four databases (Cochrane, Pubmed, EMBASE and CINAHL) yielded 3124 studies. 101 studies (including heart, kidney, liver, and lung transplant candidate populations) met the inclusion criteria.

Results

We found that studies used a wide range of frailty tools (N = 22), including four ‘established’ frailty tools. The most commonly used tools were the Fried Frailty Phenotype and the Liver Frailty Index. Frailty prevalence estimates for this middle-aged, predominantly male, population varied between 2.7% and 100%. In the SOT candidate population, frailty was found to be associated with a range of adverse outcomes, with most evidence for increased mortality (including post-transplant and wait-list mortality), post-operative complications and prolonged hospitalisation. There is currently insufficient data to compare the predictive validity of frailty tools in the SOT population.

Conclusion

Overall, there is great variability in the approach to frailty measurement in this population. Preferably, a validated frailty measurement tool would be incorporated into SOT eligibility assessments internationally with a view to facilitating comparisons between patient sub-groups and national and international transplant services with the ultimate goal of improved patient care.

Proteinuria as a Nascent Predictor of Frailty Among People With Metabolic Syndrome: A Retrospective Observational Study

Frailty is a commonly occurring geriatric condition that increases the risk of adverse health outcomes. The factors and predictors behind frailty are not yet well understood. A better understanding of these factors can enable prevention of frailty in elderly patients. The objective of this study was to determine the association between proteinuria and frailty in US individuals with metabolic syndrome (MetS). Data from the National Health and Nutrition Examination Survey III (NHANES III, 1988–1994) conducted by the National Center for Health Statistics of the Centers for Disease Control and Prevention. This is a cross-sectional study, and proteinuria and frailty were measured only once at enrollment. The study included 2,272 participants with MetS aged 40–90 years from the NHANES III. The participants underwent assessments to evaluate frailty and frailty components (low body weight, weakness, exhaustion, low physical activity, and slow walking). Proteinuria was represented as albumin-to-creatinine ratio (ACR) (mg/g) and divided into tertiles: T1-normal range (ACR <30 mg/g), T2-microalbuminuria (ACR 30–299 mg/g), and T3-macroalbuminuria (ACR ≥ 300 mg/g). We applied multiple logistic regression to determine the odds ratios (ORs) of frailty for T2 vs. T1 and T3 vs. T1 in both sexes. In the adjusted analysis for male participants, the ORs of frailty for T2 and T3 vs. T1 were 3.106 (95% confidence interval [CI] = 1.078–8.948, P = 0.036) and 14.428 (95% CI = 4.231–49.193, P < 0.001), respectively. For female participants, the ORs of frailty for T2 and T3 vs. T1 were 1.811 (95% CI = 1.071–3.063, P = 0.027) and 2.926 (95% CI = 1.202–7.124, P = 0.018), respectively. The positive association between T2 and T3 vs. T1, and frailty were statistically significant. The trends of higher likelihood of every frailty component were also statistically significant across increasing tertiles of proteinuria after multiple levels of adjustment for covariates (P < 0.05). Increased proteinuria levels were positively associated with frailty and each frailty component. Proteinuria might be a useful maker for frailty in individuals with MetS.

Composite Biomarkers for Assessing Frailty Status in Stable Older Adults With Cardiovascular Disease

Background: The relationship between frailty status and laboratory measurements in cardiovascular disease (CVD) remains unclear. We investigated which laboratory measurements indicated frailty in stable older CVD patients.

Methods and Results: One-hundred thirty-eight stable older CVD patients were evaluated by laboratory measurements, with frailty assessed using the Kihon Checklist (KCL). Laboratory measurements were compared between frail and non-frail groups. Across the entire cohort, mean age was 81.7 years, mean left ventricular ejection fraction was 57.8%, and mean plasma B-type natriuretic peptide was 182 pg/mL. KCL scores were used to divide patients into non-frail (n=43; KCL <8) and frail (n=95; KCL ≥8) groups. Serum iron was significantly lower in the frail than non-frail group (mean [±SD] 61.2±30.3 vs. 89.5±26.1 μg/dL, respectively; P<0.001). Blood urea nitrogen (BUN; 27.3±16.5 vs. 19.7±8.2 mg/dL; P=0.013) and C-reactive protein (CRP; 1.05±1.99 vs. 0.15±0.21 mg/dL; P=0.004) were significantly higher in the frail than non-frail group. Multivariate analysis revealed that serum iron, CRP, and BUN were significant independent predictors of frailty (β=−0.069, 0.917, and 0.086, respectively).

Conclusions: Frailty status was significantly associated with iron, CRP, and BUN in stable older CVD patients. Composite biomarkers (inflammation, iron deficiency, and renal perfusion) may be useful for assessing frailty in these patients.

Physical, Psychological and Social Frailty Are Predictive of Heart Failure: A Cross-Sectional Study

Background: Little is known about frailty among patients hospitalized with heart failure (HF). To date, the limited information on frailty in HF is based on a unidimensional view of frailty, in which only physical aspects are considered when determining frailty. The aims of this study were to study different dimensions of frailty (physical, psychological and social) in patients with HF and the effect of different dimensions of frailty on the incidence of heart failure. Methods: The study used a cross-sectional design and included 965 patients hospitalized for heart failure and 164 healthy controls. HF was defined according to the ESC guidelines. The Tilburg Frailty Indicator (TFI) was used to assess frailty. Probit regression analyses and chi-square statistics were used to examine associations between the occurrence of heart failure and TFI domains of frailty. Results: Patients diagnosed with frailty were 15.3% more likely to develop HF compared to those not diagnosed with frailty (p < 0.001). An increase in physical, psychological and social frailty corresponded to an increased risk of HF of 2.9% (p < 0.001), 4.4% (p < 0.001) and 6.6% (p < 0.001), respectively. Conclusions: We found evidence of the association between different dimensions of frailty and incidence of HF.

Frailty screening in older adults: is annual screening necessary in primary care?

BACKGROUND

The Case-finding for Complex Chronic Conditions in Adults 75+ (C5-75) involves annual frailty screening in primary care using dual-trait screening measures of handgrip strength and gait speed, with additional screening for co-existing conditions in those deemed frail.

OBJECTIVE

To identify low-risk individuals who could be screened for frailty every 2 years, rather than annually.

METHODS

This study examined a prospective cohort of patients who completed at least two annual C5-75 screenings between April 2014 and December 2018. Handgrip strength and gait speed on initial assessment were categorized based on proximity to frailty thresholds and were used to predict frailty risk on the second assessment. We used Fisher's exact test to assess differences in risk. Logistic regression models tested associations between independent variables of age, patient activity level, falls history, grip strength and gait speed on first assessment and dependent variable of frailty on subsequent assessment.

RESULTS

Analyses included 571 patients with two annual assessments. Frailty risk on the second assessment was significantly higher for patients who had gait speed or grip strength within 20% of the frailty threshold (5.7%), compared with the other categories (0.7%, 0.9%, 0%; P = 0.002); 60% of patients fell within these lower risk categories. Controlling for grip strength and gait speed, no other measures had significant associations with frailty risk.

CONCLUSIONS

Our results demonstrate that 60% patients are at low risk (<1%) of transitioning to frailty by the next annual assessment. Reducing screening frequency from annually to every 2 years may be appropriate for these patients.

Association of frailty with in-hospital outcomes in elderly patients with heart failure

BACKGROUND

Frailty is prevalent in elderly patients with cardiovascular diseases. However, the association between frailty and in-hospital outcomes for elderly patients with heart failure and reduced ejection (HFrEF) remains unknown.

AIM

To evaluate the predictive efficacy of frailty, compared with pre-frailty, for adverse events in these patients.

METHODS

Elderly patients (≥ 60 years) with HFrEF were assessed. Frailty was evaluated with the Fried phenotype criteria, and physical performance was evaluated based on handgrip strength and the short physical performance battery (SPPB). The composite incidence of adverse events, including all-cause death, multiple organ failure, cardiac shock, and malignant arrhythmia, during hospitalization was recorded.

RESULTS

Overall, 252 elderly individuals with HFrEF [mean age: 69.4 ± 6.7 years, male: 169 (67.0%)] were included. One hundred and thirty-five (53.6%) patients were frail and 93 (36.9%) were pre-frail. Frail patients were older, more likely to be female, to have a lower blood pressure, and to present with left ventricular thrombosis (P all < 0.05). Frail patients with HFrEF had a higher incidence of in-hospital mortality (11.9% vs 4.3%, P = 0.048). Multivariate analyses showed that female gender (OR = 0.422), aging (OR = 1.090), poor cardiac functional class (OR = 2.167), frailty (OR = 2.379), and lower handgrip strength (OR = 1.106) were independent predictors of in-hospital adverse events (P all < 0.05).

CONCLUSION

Frailty may be associated with poor in-hospital outcomes for elderly patients with HFrEF. The influence of frailty on long-term prognosis in these patients deserves further investigation.

[Geriatric and social assessment by the heart failure patients' nurse in the FIL-EAS ic]

The use of geriatric and social assessment grids by dedicated nurses for patients hospitalised for acute heart failure allows for an early and safe return home in home hospitalisation. These grids isolate a sub-group of older patients with a high risk of re-hospitalisation for whom specific actions can be envisaged.

Prevention and Reversal of Frailty in Heart Failure - A Systematic Review

BACKGROUND

Frailty is prevalent in patients with heart failure (HF) and associated with increased morbidity and mortality. Hence, there has been increased interest in the reversibility of frailty following treatment with medication or surgery. This systematic review aimed to assess the reversibility of frailty in patients with HF before and after surgical interventions aimed at treating the underlying cause of HF. It also aimed to assess the efficacy of cardiac rehabilitation and prehabilitation in reversing or preventing frailty in patients with HF.Methods and Results:Searches of PubMed, MEDLINE and Academic Search Ultimate identified studies with HF patients undergoing interventions to reverse frailty. Titles, abstracts and full texts were screened for eligibility based on the PRISMA guidelines and using predefined inclusion/exclusion criteria in relation to participants, intervention, control, outcome and study design. In total, 14 studies were included: 3 assessed the effect of surgery, 7 assessed the effect of rehabilitation programs, 2 assessed the effect of a prehabilitation program and 2 assessed the effect of program interruptions on HF patients.

CONCLUSIONS

Overall, it was found that frailty is at least partially reversible and potentially preventable in patients with HF. Interruption of rehabilitation programs resulted in deterioration of the frailty status. Future research should focus on the role of prehabilitation in mitigating frailty prior to surgical intervention.

Association of adipokines with frailty in heart failure

Background

Frailty is a multifactorial physiological syndrome most often associated with age but which has received increasing recognition as a component of chronic illnesses such as heart failure. Patients with heart failure are likely to be frail, irrespective of their age. Adipokine dysregulation, which is associated with frailty, occurs in patients with heart failure. In this study, we tested the hypothesis that adipokines are associated with skeletal muscle and bone mineral density that change lead to frailty in patients with heart failure.

Methods

Thirty-five patients with heart failure (age, 67 ± 14 years; 25 males; left ventricular ejection fraction, 45 ± 19%) were included. Serum adipokine levels, physical performance, and body composition were measured.

Results

Adiponectin and leptin were inversely correlated with grip strength. Adiponectin was inversely correlated with bone mineral density. Leptin was positively correlated with fat mass. Adipokines were not correlated with skeletal muscle mass.

Conclusions

Adipokines were associated with grip strength and bone mineral density in patients with heart failure. Adipokine dysregulation may play a role in the development of frailty in heart failure.

Frailty is highly prevalent in specific cardiovascular diseases and females, but significantly worsens prognosis in all affected patients: A systematic review

Cardiologists are more often confronted with older (>60 years) cardiovascular disease (CVD) patients. These patients have particular needs in clinical care because, for example, of frailty. However, it remains to be established what is the prevalence of frailty in different CVD's and how it relates to mortality. In this systematic review studies were included if they: (i) examined subjects (men and women) aged ≥60 years who suffered from any CVD with or without cardiac surgery, (ii.) examined the presence of frailty with a well-defined frailty tool and (iii.) reported prevalence rates of frailty. From thirty studies comprising 96.841 participants, it is found that 1. Frailty is highly common in older patients with CVD (in particular in females (approximately 1.6 times more than in males), in heart failure (up to 80 % of patients) and aortic valve disease (up to 74 % of patients)), and 2. Frailty is related to a 2.5-3.5-fold elevated mortality risk, even in patients with less severe CVD (e.g. percutaneous coronary intervention). Moreover, there is a lack of consistency on how to assess frailty as up to 20 different tools/assessment batteries are currently used. It is concluded that frailty should be assessed in all older CVD patients in a uniform manner to enhance clinical care and outcomes.

Role of Cachexia and Fragility in the Patient Candidate for Cardiac Surgery

Frailty is the major expression of accelerated aging and describes a decreased resistance to stressors, and consequently an increased vulnerability to additional diseases in elderly people. The vascular aging related to frail phenotype reflects the high susceptibility for cardiovascular diseases and negative postoperative outcomes after cardiac surgery. Sarcopenia can be considered a biological substrate of physical frailty. Malnutrition and physical inactivity play a key role in the pathogenesis of sarcopenia. We searched on Medline (PubMed) and Scopus for relevant literature published over the last 10 years and analyzed the strong correlation between frailty, sarcopenia and cardiovascular diseases in elderly patient. In our opinion, a right food intake and moderate intensity resistance exercise are mandatory in order to better prepare patients undergoing cardiac operation.

Association of lower extremity function with nutritional status and number of drugs in patients with chronic heart failure

OBJECTIVE

This study was performed to investigate the physical performance parameters, including lower extremity function parameters, that may be risk factors for falls in patients with chronic heart failure.

METHODS

Seventy patients with stable chronic heart failure were included in this retrospective cross-sectional study. The five-repetition sit-to-stand test (5STS) time, Controlling Nutritional Status (CONUT) score, and number of drugs were assessed.

RESULTS

Simple linear regression analysis revealed that the 5STS time was positively correlated with age, the CONUT score, and the number of drugs but was negatively associated with the handgrip force, quadriceps force, and quadriceps muscle thickness. Multiple linear regression analysis showed a significant association between the 5STS time and the CONUT score, quadriceps force, and number of drugs.

CONCLUSION

The muscle strength, nutritional status, and number of drugs should be evaluated to prevent lower extremity weakness in patients with stable chronic heart failure.

Left ventricular systolic dysfunction is associated with poor functional outcomes after endovascular thrombectomy

BACKGROUND

Endovascular thrombectomy (ET) has transformed acute ischemic stroke (AIS) therapy in patients with large vessel occlusion (LVO). Left ventricular systolic dysfunction (LVSD) decreases global cerebral blood flow and predisposes to hypoperfusion. We evaluated the relationship between LVSD, as measured by LV ejection fraction (LVEF), and clinical outcomes in patients with anterior cerebral circulation LVO who underwent ET.

METHODS

This multicenter retrospective cohort study examined anterior circulation LVO AIS patients from six international stroke centers. LVSD was measured by assessment of the echocardiographic LVEF using Simpson's biplane method of discs according to international guidelines. LVSD was defined as LVEF <50%. The primary outcome was defined as a good functional outcome using a modified Rankin Scale (mRS) of 0-2 at 3 months.

RESULTS

We included 440 AIS patients with LVO who underwent ET. On multivariate analyses, pre-existing diabetes mellitus (OR 2.05, 95% CI 1.24 to 3.39;p=0.005), unsuccessful reperfusion (Treatment in Cerebral Infarction (TICI) grade 0-2a) status (OR 4.21, 95% CI 2.04 to 8.66; p<0.001) and LVSD (OR 2.08, 95% CI 1.18 to 3.68; p=0.011) were independent predictors of poor functional outcomes at 3 months. On ordinal (shift) analyses, LVSD was associated with an unfavorable shift in the mRS outcomes (OR 2.32, 95% CI 1.52 to 3.53; p<0.001) after adjusting for age and ischemic heart disease.

CONCLUSION

Anterior circulation LVO AIS patients with LVSD have poorer outcomes after ET, suggesting the need to consider cardiac factors for ET, the degree of monitoring and prognostication post-procedure.

Impact of Galectin-3 Circulating Levels on Frailty in Elderly Patients with Systolic Heart Failure

Background: Heart Failure (HF), a leading cause of morbidity and mortality, represents a relevant trigger for the development of frailty in the elderly. Inflammation has been reported to play an important role in HF and frailty pathophysiology. Galectin-3 (Gal-3), whose levels increase with aging, exerts a relevant activity in the processes of cardiac inflammation and fibrosis. The aim of the present study was to investigate the potential of Galectin-3 to serve as a biomarker of frailty in HF patients. Methods: 128 consecutive patients aged 65 and older with the diagnosis of systolic HF underwent a frailty assessment and blood sample collection for serum Gal-3 detection. A multivariable regression analysis and decision curve analysis (DCA) were used to identify significant predictors of frailty. Results: Frailty was present in 42.2% of patients. Age: Odds Ratio (OR) = 3.29; 95% Confidence Interval CI (CI) = 1.03-10.55, Cumulative Illness Rating Scale Comorbidity Index (CIRS-CI): OR = 1.85; 95% CI = 1.03-3.32, C-Reactive phase Protein (CRP) OR = 3.73; 95% CI = 1.24-11.22, N-terminal-pro-Brain Natriuretic Peptide (NT-proBNP): OR = 2.39; 95% CI = 1.21-4.72 and Gal-3: OR = 5.64; 95% CI = 1.97-16.22 resulted in being significantly and independently associated with frailty. The DCA demonstrated that the addition of Gal-3 in the prognostic model resulted in an improved clinical 'net' benefit. Conclusions: Circulating levels of Gal-3 are independently associated with frailty in elderly patients with systolic HF.

The C5-75 Program: Meeting the Need for Efficient, Pragmatic Frailty Screening and Management in Primary Care

Case-Finding for Complex Chronic Conditions in Seniors 75+ (C5-75) is a systematic approach to identify frailty using gait speed and hand-grip strength and to screen for co-morbid conditions. We identified the C5-75 features offering the highest yield for identifying frailty and to streamline the screening program. Analyses included 1,948 C5-75 assessments completed from 2013 to 2018. Age 85 or older, less than regular physical activity, and more than two falls in the previous six months had the strongest associations with frailty. Exempting patients under 85 who reported regular physical activity and less than two falls excluded 39.1 per cent of the cohort while maintaining a sensitivity of 95.2 per cent and a negative predictive value of 99.4 per cent for frailty. These findings provide insight into optimizing screening for frailty, making it more feasible to implement and to identify co-existing conditions that may contribute to or be affected by frailty.

Addressing Social Determinants of Health in the Care of Patients With Heart Failure: A Scientific Statement From the American Heart Association

Heart failure is a clinical syndrome that affects >6.5 million Americans, with an estimated 550 000 new cases diagnosed each year. The complexity of heart failure management is compounded by the number of patients who experience adverse downstream effects of the social determinants of health (SDOH). These patients are less able to access care and more likely to experience poor heart failure outcomes over time. Many patients face additional challenges associated with the cost of complex, chronic illness management and must make difficult decisions about their own health, particularly when the costs of medications and healthcare appointments are at odds with basic food and housing needs. This scientific statement summarizes the SDOH and the current state of knowledge important to understanding their impact on patients with heart failure. Specifically, this document includes a definition of SDOH, provider competencies, and SDOH assessment tools and addresses the following questions: (1) What models or frameworks guide healthcare providers to address SDOH? (2) What are the SDOH affecting the delivery of care and the interventions addressing them that affect the care and outcomes of patients with heart failure? (3) What are the opportunities for healthcare providers to address the SDOH affecting the care of patients with heart failure? We also include a case study ( Data Supplement ) that highlights an interprofessional team effort to address and mitigate the effects of SDOH in an underserved patient with heart failure.

Heart failure, frailty, and pre-frailty: A systematic review and meta-analysis of observational studies

Frailty is a syndrome characterized by reduced physiological reserves, increased vulnerability to stressors and adverse health outcomes. Frailty can change the prognosis and treatment approach of several chronic diseases, including heart failure (HF). The aim of this study was to conduct a systematic review and meta-analysis assessing the association of HF with frailty and pre-frailty. We employed PRISMA guidelines for reporting the results. We searched PubMed, Web of Science, and Embase from 01/01/2002 to 29/11/2019.The quality of the studies was evaluated with the Newcastle Ottawa Scale. Pooled estimates were obtained through random-effect models and Mantel-Haenszel weighting. Homogeneity (I²) and publication bias were assessed. We selected 54 studies (52 cross-sectional, one longitudinal, and one with both designs). The pooled prevalence of pre-frailty in individuals with HF was 46% (95% CI = 38-53; I² = 93.1%) and 40% (95% CI = 31-48; I² = 97%) for frailty. The proportion of pre-frail individuals with HF was 20% (95%CI = 15-25; I² = 99.2%) and the proportion of frail individuals with HF was 31% (95% CI = 17-45; I² = 98.7%). Two studies using the same frailty definition reported estimates for the association between frailty and HF (pooled OR = 3.44; 95% CI = 0.75-15.73; I² = 95.8%). In conclusion, frailty and pre-frailty are frequent in people with HF. Persons with HF have 3.4-fold increased odds of frailty. Longitudinal studies examining bidirectional pathophysiological pathways between HF and frailty are needed to further clarify this relationship and to assess if specific treatment for HF may prevent or delay the onset of frailty and vice versa.

Outcome measures in a combined exercise rehabilitation programme for adults with COPD and chronic heart failure: A preliminary stakeholder consensus event

Combined exercise rehabilitation for chronic obstructive pulmonary disease (COPD) and chronic heart failure (CHF) is potentially attractive. Uncertainty remains as to the baseline profiling assessments and outcome measures that should be collected within a programme. Current evidence surrounding outcome measures in cardiac and pulmonary rehabilitation were presented by experts at a stakeholder consensus event and all stakeholders (n = 18) were asked to (1) rank in order of importance a list of categories, (2) prioritise outcome measures and (3) prioritise baseline patient evaluation measures that should be assessed in a combined COPD and CHF rehabilitation programme. The tasks were completed anonymously and related to clinical rehabilitation programmes and associated research. Health-related quality of life, exercise capacity and symptom evaluation were voted as the most important categories to assess for clinical purposes (median rank: 1, 2 and 3 accordingly) and research purposes (median rank; 1, 3 and 4.5 accordingly) within combined exercise rehabilitation. All stakeholders agreed that profiling symptoms at baseline were ‘moderately’, ‘very’ or ‘extremely’ important to assess for clinical and research purposes in combined rehabilitation. Profiling of frailty was ranked of the same importance for clinical purposes in combined rehabilitation. Stakeholders identified a suite of multidisciplinary measures that may be important to assess in a combined COPD and CHF exercise rehabilitation programme.

Primary care interventions to address physical frailty among community-dwelling adults aged 60 years or older: A meta-analysis

Introduction

The best interventions to address frailty among older adults have not yet been fully defined, and the diversity of interventions and outcome measures makes this process challenging. Consequently, there is a lack of guidance for clinicians and researchers regarding which interventions are most likely to help older persons remain robust and independent. This paper uses meta-analysis to assess effectiveness of primary care interventions for physical frailty among community-dwelling adults aged 60+ and provides an up-to-date synthesis of literature in this area.

Methods

PubMed, CINAHL, Cochrane Register of Controlled Trials, and PEDro databases were searched, and RCTs, controlled pilot studies, or trials with similar study designs addressing frailty in the primary care setting among persons aged 60+ were chosen. Study data was abstracted following PRISMA guidelines, then meta-analysis was performed using the random effects model.

Results

31 studies with a total of 4794 participants were analysed. Interventions using predominantly resistance-based exercise and nutrition supplementation seemed to improve frailty status versus control (RR = 0.62 (CI 0.48–0.79), I² = 0%). Exercise plus nutrition education also reduced frailty (RR = 0.69 (CI 0.58–0.82), I² = 0%). Exercise alone seemed effective in reducing frailty (RR = 0.63 (CI 0.47–0.84), I² = 0%) and improving physical performance (RR = 0.43 (CI 0.18–0.67), I² = 0%). Exercise alone also appeared superior to control in improving gait speed (SMD = 0.36 (CI 0.10–0.61, I² = 74%), leg strength (SMD = 0.61 (CI 0.09–1.13), I² = 87%), and grip strength (Mean Difference = 1.08 (CI 0.02–2.15), I² = 71%) though a high degree of heterogeneity was observed. Comprehensive geriatric assessment (RR = 0.77 (CI 0.64–0.93), I² = 0%) also seemed superior to control in reducing frailty.

Conclusion

Exercise alone or with nutrition supplementation or education, and comprehensive geriatric assessment, may reduce physical frailty. Individual-level factors and health systems resource availability will likely determine configuration of future interventions.

Improving the design of heart failure care from the perspective of frontline providers and administrators: A qualitative case study of a large, urban health system

BACKGROUND

Heart failure patients often present with frailty and/or multi-morbidity, complicating care and service delivery. The Chronic Care Model (CCM) is a useful framework for designing care for complex patients. It assumes responsibility of several actors, including frontline providers and health-care administrators, in creating conditions for optimal chronic care management. This qualitative case study examines perceptions of care among providers and administrators in a large, urban health system in Canada, and how the CCM might inform redesign of care to improve health system functioning.

METHODS

Sixteen semi-structured interviews were conducted between August 2014 and January 2016. Interpretive analysis was conducted to identify how informants perceive care among this population and the extent to which the design of heart failure care aligns with elements of the CCM.

RESULTS

Current care approaches could better align with CCM elements. Key changes to improve health system functioning for complex heart failure patients that align with the CCM include closing knowledge gaps, standardizing treatment, improving interdisciplinary communication and improving patient care pathways following hospital discharge.

CONCLUSIONS

The CCM can be used to guide health system design and interventions for frail and multi-morbid heart failure patients. Addressing care- and service-delivery barriers has important clinical, administrative and economic implications.

Care plans for the older heart failure patient

Heart failure (HF) professionals are managing an older population with multiple, often interconnected comorbidities. The average age of the HF patient has increased substantially and many have a number of comorbidities. For the older HF patient, diligent planning of care has the potential to reduce hospitalization, improve quality of life and mortality; nevertheless, this vital component is often overlooked. Frailty, cachexia, sarcopenia, and cognitive impairment are all common in the older HF patient and require special care considerations. Many older HF patients live for many years with troublesome symptoms that could be better addressed through the incorporation of a palliative approach to care. Effective care plans can help patients maximize their health potential through both lifestyle and pharmacological interventions. However, current evidence remains scarce on what constitutes an optimal plan, therefore further studies are urgently needed. We review the care that could be implemented for the complex older HF patient with comorbidities.

Assess frailty but avoid frailtyism

The assessment of frailty in heart failure patients can help clinicians to build a tailored care plan, aimed at improving the selection of patients likely to benefit from one treatment vs. another, thereby improving outcomes. Although progress has been made in the ‘operationalization’ of frailty assessment, there is still the need to provide an improved instrument to assess frailty that is easy, quick and at the same time predictive within the setting of a busy clinical practice. Using such an ideal instrument, clinicians would be able to optimize the use of limited health care resources and avoid what has been termed ‘frailtyism’. This term, similar to ageism, can be defined as prejudice or discrimination based on the presence of frailty.

Impact of Frailty on Mortality and Hospitalization in Chronic Heart Failure: A Systematic Review and Meta-Analysis

Background

Although frailty has been associated with increased risks for hospitalization and mortality in chronic heart failure, the precise average effect remains uncertain. We performed a systematic review and meta‐analysis to summarize the hazards for mortality and incident hospitalization in patients with heart failure and frailty compared with those without frailty and explored the heterogeneity underlying the effect size estimates.

Methods and Results

MEDLINE, EMBASE, and Cochrane databases were queried for articles published between January 1966 and March 2018. Predefined selection criteria were used. Hazard ratios (HRs) were pooled for meta‐analyses, and where odds ratios were used previously, original data were recalculated for HR. Overlapping data were consolidated, and only unique data points were used. Study quality and bias were assessed. Eight studies were included for mortality (2645 patients), and 6 studies were included for incident hospitalization (2541 patients) during a median follow‐up of 1.82 and 1.12 years, respectively. Frailty was significantly associated with an increased hazard for mortality (HR, 1.54; 95% confidence interval, 1.34–1.75; P<0.001) and incident hospitalization (HR, 1.56; 95% confidence interval, 1.36–1.78; P<0.001) in chronic heart failure. The Fried phenotype estimated a 16.9% larger effect size than the combined Fried/non‐Fried frailty assessment for the end point of mortality (HR, 1.80; 95% confidence interval, 1.41–2.28; P<0.001), but not for hospitalization (HR, 1.57; 95% confidence interval, 1.30–1.89; P<0.001). Study heterogeneity was found to be low (I²=0%), and high quality of studies was verified by the Newcastle‐Ottawa scale.

Conclusions

Overall, the presence of frailty in chronic heart failure is associated with an increased hazard for death and hospitalization by ≈1.5‐fold.

Heart Failure in Ischemic Stroke

Background and Purpose—

Heart failure (HF) in patients with acute ischemic stroke constitutes the source of various detrimental pathophysiologic mechanisms including prothrombotic and proinflammatory states, worsening of cerebral tissue oxygenation, and hemodynamic impairment. In addition, HF might affect the safety and efficacy of the acute recanalization stroke therapies.

Methods—

Patients treated with intravenous recombinant tissue-type plasminogen activator or mechanical recanalization at a universitary stroke center were included into a prospective registry. Patients received cardiological evaluation, including echocardiography, during acute care. Functional outcome was assessed after 90 days by structured telephone interviews. Safety and efficacy of intravenous thrombolysis and mechanical thrombectomy were investigated among patients with HF and compared with patients with normal cardiac function after propensity score matching.

Results—

One thousand two hundred nine patients were included. HF was present in 378 patients (31%) and an independent predictor of unfavorable functional outcome. Recanalization rates were equal among patients with HF after intravenous thrombolysis and after mechanical recanalization or combined treatment. The rate of secondary intracranial hemorrhage was not different (7% versus 8%; P =0.909 after thrombolysis and 15% versus 20%, P =0.364 after mechanical recanalization or combined therapy). Early mortality within 48 hours after admission was equal (<1.5% in both groups).

Conclusions—

In this real-world cohort of patients with stroke, HF was an independent predictor of unfavorable functional long-term outcome, while the safety and efficacy of intravenous thrombolysis and mechanical recanalization appeared unaffected.

Using Physical Function to Predict Hospital Readmission within 1 Year in Patients with Heart Failure

OBJECTIVE

The aim of this study was to investigate which method of evaluating physical function could predict 1-year readmission due to worsening of heart failure (HF) in newly diagnosed HF patients.

METHODS

One hundred sixteen consecutive patients with HF who underwent cardiac rehabilitation at our hospital between May 2012 and September 2015 were retrospectively enrolled. Participants were divided into two groups based on whether they were readmitted for worsening HF within 1 year. Logistic regression analysis was used to evaluate whether physical function at the time of discharge was related to HF readmission within 1 year.

RESULTS

After a mean follow-up period of 327 days, 22 patients were readmitted because of worsening HF. In the readmission group, the results of the 6-Minute Walk Test (6MWT), One-Leg Standing Test, and 30-Second Chair-Stand Test at initial discharge were significantly worse than those in the non-readmission group. In a multivariable logistic regression model, after adjusting for age and sex, a lower 6MWT distance was independently associated with increased risk of readmission within 1 year (odds ratio: 0.990, 95% confidence interval: 0.985-0.996). The 6MWT showed better prognostic value (area under the receiver operating characteristic curve: 0.696) than other evaluation methods of physical function. The 1-year non-readmission rates were 90% for 6MWT ≥382.5 m, 68% for 6MWT <382.5 m, and 53% for those unable to walk 200 m independently (P <0.001).

CONCLUSION

Physical function, particularly the 6MWT distance at time of discharge, can be used to predict the likelihood of readmission within 1 year for patients with HF.

Assessment of frailty syndrome using Edmonton frailty scale in Polish elderly sample

The aim of the study was to assess the incidence and severity of the frailty syndrome assessed with the Edmonton Frailty Scale. This is a cross-sectional study conducted among 382 patients (236 men and 146 women, mean age 71.9 years). The Edmonton Frailty Scale was administered during the patient's admission to the hospital. The Polish adaptation was performed using the standard methodology. The Cronbach's alpha coefficient for the whole Edmonton Frailty Scale was 0.709. The mean correlation between positions and the overall result was r = 0.180. There were no statistically significant differences between women and men in the area of Edmonton Frailty Scale mean score (p < 0.05). The socio-clinical analysis, showed statistically significant differences in the age of respondents, educational attainment, occupational activity, number of drugs taken and co-occurrence of chronic diseases. A higher values of the Edmonton Frailty Scale were indicated for individuals >70 years than for those <70 years (p < 0.001). The Edmonton Frailty Scale proved to be a reliable tool which may be used in the Polish population. The use of this questionnaire for frailty syndrome may be helpful in everyday clinical practice.

2019 EACTS Expert Consensus on long-term mechanical circulatory support

Long-term mechanical circulatory support (LT-MCS) is an important treatment modality for patients with severe heart failure. Different devices are available, and many-sometimes contradictory-observations regarding patient selection, surgical techniques, perioperative management and follow-up have been published. With the growing expertise in this field, the European Association for Cardio-Thoracic Surgery (EACTS) recognized a need for a structured multidisciplinary consensus about the approach to patients with LT-MCS. However, the evidence published so far is insufficient to allow for generation of meaningful guidelines complying with EACTS requirements. Instead, the EACTS presents an expert opinion in the LT-MCS field. This expert opinion addresses patient evaluation and preoperative optimization as well as management of cardiac and non-cardiac comorbidities. Further, extensive operative implantation techniques are summarized and evaluated by leading experts, depending on both patient characteristics and device selection. The faculty recognized that postoperative management is multidisciplinary and includes aspects of intensive care unit stay, rehabilitation, ambulatory care, myocardial recovery and end-of-life care and mirrored this fact in this paper. Additionally, the opinions of experts on diagnosis and management of adverse events including bleeding, cerebrovascular accidents and device malfunction are presented. In this expert consensus, the evidence for the complete management from patient selection to end-of-life care is carefully reviewed with the aim of guiding clinicians in optimizing management of patients considered for or supported by an LT-MCS device.

Evaluating the convergent and discriminant validity of three versions of the frailty phenotype in heart failure: results from the FRAME-HF study

BACKGROUND

Frailty is an important predictive measure of mortality and rehospitalisation in people with heart failure. To date, there are no frailty instruments validated for use in people with heart failure.

AIM

The aim of this study was to evaluate the convergent and discriminant validity of three versions of the frailty phenotype in those with heart failure.

METHODS

A single site, prospective cohort study was undertaken among individuals with a confirmed diagnosis of heart failure. Frailty was assessed concurrently using three versions of the frailty phenotype: the original frailty phenotype and two modified versions; the Survey of Health, Ageing and Retirement in Europe frailty instrument (SHARE-FI) and the St Vincent's frailty instrument. Convergent and discriminant validity were assessed by reporting the correlations between each version and related heart failure subconstructs, and by evaluating the ability of each version to discriminate between normal and abnormal scores of other physical and psychosocial scales specific to heart failure-related subconstructs.

RESULTS

The New York Heart Association classes were moderately correlated with the St Vincent's frailty instrument (r=0.47, P⩽0.001), SHARE-FI (r=0.42, P⩽0.001) and the frailty phenotype (r=0.42, P⩽0.001). The SHARE-FI and the St Vincent's frailty instrument were both able to discriminate consistently between normal and abnormal scores in three out of five of the physical and psychosocial subconstructs that were assessed. The SHARE-FI was also able to discriminate between inpatients and outpatients who were classified as frail.

CONCLUSIONS

Both the SHARE-FI and the St Vincent's frailty instrument displayed good convergent and discriminant validity.

Protocol for a feasibility trial to inform the development of a breathlessness rehabilitation programme for chronic obstructive pulmonary disease and chronic heart failure (the COHERE trial)

INTRODUCTION

Adults with chronic obstructive pulmonary disease (COPD) and chronic heart failure (CHF) commonly suffer from exertional dyspnoea and fatigue. Exercise training is recommended in the management of both diseases, yet many of the outcome measures traditionally reported are disease specific and may not fully acknowledge the multimorbid older adult. Based on our previous research, a breathlessness rehabilitation programme for patients with COPD/CHF or combined disease has been introduced as a service improvement within University Hospital Leicester National Health Service Trust and has amalgamated aspects of cardiac and pulmonary rehabilitation. This has created an opportunity to expand the outcome measures assessed and introduce a holistic approach in a population that share common symptoms. Therefore, this multisite trial will explore the feasibility of collecting novel outcome markers as part of a comprehensive assessment prior to enrolment in a breathlessness rehabilitation programme for participants with COPD and/or CHF.

METHODS AND ANALYSIS

The rehabilitation programme consists of 12 sessions, twice weekly, over a 6-week period. In addition to usual rehabilitation outcome measures, the trial will collect measures of future cardiometabolic risk including arterial stiffness, body composition, physical activity/sedentary time, frailty and symptom burden in a comprehensive rehabilitation assessment. The primary outcome measures will centre around feasibility (eg, acceptability of the comprehensive rehabilitation assessment, intervention delivery and the experiences and attitudes of healthcare professionals and participants). Focus groups and interviews will be conducted to further explore barriers and facilitators to the operation and participation in a breathlessness rehabilitation programme and the trial. Thematic analysis will be used for the interpretation of all qualitative data.

ETHICS AND DISSEMINATION

The research ethics committee East Midlands Leicester-Central has provided ethical approval for the conduct of this trial. The results of the trial will be disseminated through appropriate conference proceedings and peer-reviewed journals.

TRIAL REGISTRATION NUMBER

ISRCTN11636308.

Coexisting Frailty With Heart Failure

People over 65 years of age constitute over 80% of patients with heart failure (HF) and the incidence of HF is 10 per 1,000 in people aged above 65 years. Approximately 25% of older patients with HF exhibit evidence of frailty. Frail patients with cardiovascular disease (CVD) have a worse prognosis than non-frail patients, and frailty is an independent risk factor for incident HF among older people. Planning the treatment of individuals with HF and concomitant frailty, one should consider not only the limitations imposed by frailty syndrome (FS) but also those associated with the underlying heart disease. It needs to be emphasized that all patients with HF and concomitant FS require individualized treatment.

New insights into the pathogenesis and treatment of sarcopenia in chronic heart failure

Sarcopenia is an age-related geriatric syndrome that is characterized by a progressive loss of muscle mass, strength and function. Chronic heart failure (CHF), the final stage of various cardiovascular diseases, may be closely correlated with the occurrence of sarcopenia. Accumulating evidence has demonstrated that CHF can promote the development of sarcopenia through multiple pathophysiological mechanisms, including malnutrition, inflammation, hormonal changes, oxidative stress, autophagy, and apoptosis. Additionally, CHF can aggravate the adverse outcomes associated with sarcopenia, including falls, osteoporosis, frailty, cachexia, hospitalization, and mortality. Sarcopenia and CHF are mutually interacting clinical syndromes. Patients with these two syndromes seem to endure a double burden, with no particularly effective way to hinder their progression. However, the combination of physical exercise, nutritional supplements, and drug therapy may counteract the development of these maladies. In this review, we will summarize the latest progress in the pathogenesis and treatment of sarcopenia in patients with CHF.

Frailty Among Patients Receiving Hemodialysis: Evolution of Components and Associations With Mortality

BACKGROUND

Understanding how components of frailty change over time and how they can be modeled as time-dependent predictors of mortality could lead to better risk prediction in the dialysis population.

METHODS

We measured frailty at baseline, 12 months, and 24 months among 727 patients receiving hemodialysis in Northern California and Atlanta. We examined the likelihood of meeting frailty components (weight loss, exhaustion, low physical activity, weak grip strength, and slow gait speed) as a function of time in logistic regression analysis and association of frailty components with mortality in time-updated multivariable Cox models.

RESULTS

Physical activity and gait speed declined, exhaustion and grip strength did not change, and the odds of meeting the weight loss criterion declined with time. All five components were associated with higher mortality in multivariable analyses, but gait speed was the strongest individual predictor. All frailty components except physical inactivity were independently associated with mortality when all five components were included in the same model. The number of frailty components met was associated with mortality in a gradient that ranged from a hazard ratio of 2.73 for one component to 10.07 for five components met; the model including all five components was the best model based on Akaike information criterion.

CONCLUSIONS

Measurement of all frailty components was necessary for optimal mortality prediction, and the number of components met was strongly associated with mortality in this cohort.

Frailty is independently associated with 1-year mortality after hospitalization for acute heart failure

INTRODUCTION

Frailty is a complex condition that results from the loss of physiological reserve across multiple systems. Its presence should be considered in the aging heart failure population, since it is an important predictor of death and institutionalization in the elderly.

METHODS AND RESULTS

In a prospective, observational and analytical single-center study of 100 elderly patients hospitalized for acute heart failure, we assessed the characteristics associated with an increased hospital and 1-year mortality. Frailty was evaluated with the Clinical Frailty Scale, and there was a significant association between its presence and 1-year mortality (RR = 2.03; 95% CI = 1.18-3.48; p = 0.014), although not with in-hospital mortality. After adjusting for probable confounders, it remained independently associated with 1-year mortality.

CONCLUSION

Frailty can be assessed with a simple bed-side scale and provides significant prognostic information in acute heart failure patients.

Association Between Early Rehabilitation and Mobility Status in Elderly Inpatients with Heart Failure: A Nationwide Retrospective Cohort Study

OBJECTIVE

We set out to examine the effectiveness of early rehabilitation for maintaining mobility status during hospitalization in elderly patients with heart failure.

METHODS

Using the Japanese Diagnosis Procedure Combination inpatient database, we retrospectively examined the eligibility of 527,440 consecutive patients aged ≥60 years who were diagnosed with heart failure with New York Heart Association class ≥ II at admission between July 2010 and March 2014. Of the 146,735 eligible subjects, 39,357 underwent early rehabilitation and 107,378 underwent non-early rehabilitation. Early rehabilitation was defined as rehabilitation starting within 3 days after admission. A multivariable logistic regression analysis and an instrumental variable analysis were carried out to examine the association of early rehabilitation with changes in mobility status during hospitalization.

RESULTS

The proportion of heart failure patients with maintained or improved mobility status during hospitalization was higher in the early rehabilitation group. Multivariable logistic regression analysis revealed that the early rehabilitation group had a significantly higher proportion with maintained or improved mobility status (odds ratio, 1.32; 95% confidence interval, 1.21-1.43; P<0.001). The instrumental variable analysis showed that early rehabilitation was associated with an increased proportion of patients with maintained or improved mobility status (risk difference, 0.8%; 95% confidence interval, 0.4%-1.1%; P<0.001).

CONCLUSIONS

The present study suggests that early rehabilitation is associated with an increase in the proportion of patients with maintained or improved mobility status compared with non-early rehabilitation in elderly inpatients with heart failure.

Frailty Screening and Case-Finding for Complex Chronic Conditions in Older Adults in Primary Care

With the aging population, escalating demand for seniors' care and limited specialist resources, new care delivery models are needed to improve capacity for primary health care for older adults. This paper describes the "C5-75" (Case-finding for Complex Chronic Conditions in Seniors 75+) program, an innovative care model aimed at identifying frailty and commonly associated geriatric conditions among older adults within a Canadian family practice setting and targeting interventions for identified conditions using a feasible, systematic, evidence-informed multi-disciplinary approach. We screen annually for frailty using gait speed and handgrip strength, screen for previously undiagnosed comorbid conditions, and offer frail older adults multi-faceted interventions that identify and address unrecognized medical and psychosocial needs. To date, we have assessed 965 older adults through this program; 14% were identified as frail based on gait speed alone, and 5% identified as frail based on gait speed with grip strength. The C5-75 program aims to re-conceptualize care from reactive interventions post-diagnosis for single disease states to a more proactive approach aimed at identifying older adults who are at highest risk of poor health outcomes, case-finding for unrecognized co-existing conditions, and targeting interventions to maintain health and well-being and potentially reduce vulnerability and health destabilization.