Frailty and Cardiovascular Mortality: A Narrative Review

Exploring the connection between frailty and cardiovascular diseases

This study explores the significant correlation between frailty and an elevated risk of mortality in COVID-19 patients, suggesting that increased frailty screening could enhance disease management and optimize resource distribution. An analysis of peer-reviewed papers on frailty and cardiovascular diseases (CVD) over a ten-year period reveals a peak of 4480 articles from September 2021 to September 2022. The literature review conducted on frailty and CVD highlights the high prevalence of frailty in older adults with CVD and its role as a predictor of cardiovascular death. The study suggests that frailty can inform treatment decisions, offering more personalized care. However, standardizing frailty assessment in clinical practice and trials is needed. The impact of frailty on coronary artery disease, peripheral artery disease, and atrial fibrillation requires further research. The study also discusses the increasing global burden of CVD among older adults due to aging populations and improved care. It highlights the challenges posed by older age, multiple comorbidities, polypharmacy, frailty, and adverse noncardiovascular outcomes. The review focuses on geriatric conditions that significantly impacted health status, quality of life, and overall prognosis. The study concludes that frailty significantly increases the risk of CVD events and major adverse cardiovascular events in older adults without prior CVD. Screening for frailty could help identify those at higher risk and facilitate targeted preventive measures.

Assessment and Management of Atrial Fibrillation in Older Adults with Frailty

Atrial fibrillation (AF) is a major driver of morbidity and mortality among older adults with frailty. Moreover, frailty is highly prevalent in older adults with AF. Understanding and addressing the needs of frail older adults with AF is imperative to guide clinicians caring for older adults. In this review, we summarize current evidence to support the assessment and management of older adults with AF and frailty, incorporating numerous recent landmark trials and studies in the context of the 2023 US AF guideline.

Sex-specific effects of frailty on cardiac structure and function: insights from preclinical models

Advanced age is an independent risk factor for cardiovascular diseases in both sexes. This is thought to be due, in part, to age-dependent cellular, structural, and functional changes in the heart, a process known as cardiac aging. An emerging view is that cardiac aging leads to the accumulation of cellular and subcellular deficits that increase susceptibility to cardiovascular diseases. Still, people age at different rates, with those aging rapidly considered frail. Evidence suggests that frailty, rather than simply age, is a major risk factor for cardiovascular disease and predicts adverse outcomes in those affected. Recent studies in mouse models of frailty show that many adverse changes associated with cardiac aging are more prominent in mice with a high degree of frailty. This suggests that frailty sets the stage for late life cardiovascular diseases to flourish and raises the possibility that treating frailty may treat cardiovascular diseases. These studies show that ventricular dysfunction increases with frailty in males only, whereas atrial dysfunction increases with frailty in both sexes. These results may shed light on the reasons that men and women can be susceptible to different cardiovascular diseases as they age, and why frail individuals are especially vulnerable to these disorders.

Preclinical Studies on the Effects of Frailty in the Aging Heart

Age is a major risk factor for the development of cardiovascular diseases in men and in women. However, not all people age at the same rate and those who are aging rapidly are considered frail, compared with their fit counterparts. Frailty is an important clinical challenge because those who are frail are more likely to develop and die from illnesses, including cardiovascular diseases, than fit people of the same age. This increase in susceptibility to cardiovascular diseases in older individuals might occur as the cellular and molecular mechanisms involved in the aging process facilitate structural and functional damage in the heart. Consistent with this, recent studies in murine frailty models have provided strong evidence that maladaptive cardiac remodelling in older mice is the most pronounced in mice with a high level of frailty. For example, there is evidence that ventricular hypertrophy and contractile dysfunction increase as frailty increases in aging mice. Additionally, fibrosis and slowing of conduction in the sinoatrial node and atria are proportional to the level of frailty. These modifications could predispose frail older adults to diseases like heart failure and atrial fibrillation. This preclinical work also raises the possibility that emerging interventions designed to "treat frailty" might also treat or prevent cardiovascular diseases. These findings might help to explain why frail older people are most likely to develop these disorders as they age.

Low body mass index is associated with adverse cardiovascular outcomes following PCI in India: ACC-NCDR registry

Objective

Registry-based prospective study was conducted to evaluate association of body mass index (BMI) with major adverse coronary events (MACE) following percutaneous coronary intervention (PCI).

Methods

Successive patients undergoing PCI were enrolled from April'19 to March'22 and classified into five BMI categories (<23.0,23.0-24.9,25.0-26.9,27.0-29.9, and ≥30.0 kg/m2). Clinical, angiographic features, interventions and outcomes were obtained by in-person or telephonic follow-up. Primary endpoints were (a) MACE(cardiovascular deaths, acute coronary syndrome or stroke, revascularization, hospitalization and all-cause deaths) and (b)cardiovascular deaths. Cox-proportionate hazard ratios(HR) and 95 % confidence intervals(CI) were calculated.

Results

The cohort included 4045 patients. Mean age was 60.3 ± 11y, 3233(79.7 %) were men. There was high prevalence of cardiometabolic risk factors. 90 % patients had acute coronary syndrome(STEMI 39.6 %, NSTEMI/unstable angina 60.3 %), 60.0 % had impaired ejection fraction(EF) and multivessel CAD. Lower BMI groups (<23.0 kg/m2) had higher prevalence of tobacco use, reduced ejection fraction(EF), multivessel CAD, stents, and less primary PCI for STEMI. There was no difference in discharge medications and in-hospital deaths. Median follow-up was 24 months (IQR 12-36), available in 3602(89.0 %). In increasing BMI categories, respectively, MACE was in 10.9,8.9,9.5,9.1 and 6.8 % (R2 = 0.73) and CVD deaths in 5.1,4.5,4.4,5.1 and 3.5 % (R2 = 0.39). Compared to lowest BMI category, age-sex adjusted HR in successive groups for MACE were 0.89,0.87,0.79,0.69 and CVD deaths 0.98,0.87,0.95,0.75 with overlapping CI. HR attenuated following multivariate adjustments.

Conclusions

Low BMI patients have higher incidence of major adverse cardiovascular events following PCI in India. These patients are older, with greater tobacco use, lower EF, multivessel CAD, delayed STEMI-PCI, and longer hospitalization.

How Would You Manage This Patient With Heart Failure With Preserved Ejection Fraction? : Grand Rounds Discussion From Beth Israel Deaconess Medical Center

The proportion of patients with new-onset heart failure who have preserved rather than reduced left ventricular ejection fraction (HFpEF and HFrEF) has been increasing over recent decades. In fact, HFpEF now outweighs HFrEF as the predominant heart failure subtype and likely remains underdiagnosed in the community. This is due in part to an aging population and a rise in other risk factors for HFpEF, including obesity and associated cardiometabolic disease. Whereas the diagnosis of HFrEF is relatively straightforward, the diagnosis of HFpEF is often more challenging because there can be other causes for symptoms, including dyspnea and fatigue, and cardinal physical examination findings of elevated jugular venous pressure or pulmonary congestion may not be evident at rest. In 2022, the American College of Cardiology, the American Heart Association, and the Heart Failure Society of America published a comprehensive guideline on heart failure that included recommendations for the management of HFpEF. The use of diuretics for the management of congestion remained the only class 1 (strong) recommendation. New recommendations included broader use of sodium-glucose cotransporter-2 inhibitors (SGLT2i, class 2a), and angiotensin receptor-neprilysin inhibitors (class 2b). In 2023, the American College of Cardiology published an expert consensus decision pathway for the management of HFpEF that suggests treatment strategies based on sex assigned at birth, ejection fraction, clinical evidence of congestion, and candidacy for SGLT2i therapy. Here, 2 experts, a cardiologist and a geriatrician, discuss their approach to the diagnosis and management of HFpEF and how they would apply guidelines to an individual patient.