Frailty for predicting all-cause mortality in elderly acute coronary syndrome patients: A meta-analysis

Development and validation of frailty risk prediction model for elderly patients with coronary heart disease

OBJECTIVE

To analyze the influential factors of frailty in elderly patients with coronary heart disease (CHD), develop a nomogram-based risk prediction model for this population, and validate its predictive performance.

METHODS

A total of 592 elderly patients with CHD were conveniently selected and enrolled from 3 tertiary hospitals, 5 secondary hospitals, and 3 community health service centers in China between October 2022 and January 2023. Data collection involved the use of the general information questionnaire, the Frail scale, and the instrumental ability of daily living assessment scale. And the patients were categorized into two groups based on frailty, and χ2 test as well as logistic regression analysis were used to identify and determine the influencing factors of frailty. The nomograph prediction model for elderly patients with CHD was developed using R software (version 4.2.2). The Hosmer-Lemeshow test and the area under the receiver operating characteristic (ROC) curve were employed to assess the predictive performance of the model. Additionally, the Bootstrap resampling method was utilized to validate the model and generate the calibration curve of the prediction model.

RESULTS

The prevalence of frailty in elderly patients with CHD was 30.07%. The multiple factor analysis revealed that poor health status (OR = 28.169)/general health status (OR = 18.120), age (OR = 1.046), social activities (OR = 0.673), impaired instrumental ability of daily living (OR = 2.384) were independent risk factors for frailty (all P < 0.05). The area under the ROC curve of the nomograph prediction model was 0.847 (95% CI: 0.809 ~ 0.878, P < 0.001), with a sensitivity of 0.801, and specificity of 0.793; the Hosmer- Lemeshow χ2 value was 12.646 (P = 0.125). The model validation results indicated that the C value of 0.839(95% CI: 0.802 ~ 0.879) and Brier score of 0.139, demonstrating good consistency between predicted and actual values.

CONCLUSION

The prevalence of frailty is high among elderly patients with CHD, and it is influenced by various factors such as health status, age, lack of social participation, and impaired ability of daily life. These factors have certain predictive value for identifying frailty early and intervention in elderly patients with CHD.

Measuring Frailty Using Self-Report or Automated Tools to Identify Risk of Cardiovascular Events and Mortality: The Million Veteran Program

BACKGROUND

Frailty, a syndrome of physiologic vulnerability, increases cardiovascular disease (CVD) risk. Whether in person or automated frailty tools are ideal for identifying CVD risk remains unclear. We calculated 3 distinct frailty scores and examined their associations with mortality and CVD events in the Million Veteran Program, a prospective cohort of nearly 1 million US veterans.

METHODS AND RESULTS

Veterans aged ≥50 years and enrolled from 2011 to 2018 were included. Two frailty indices (FI) based on the deficit accumulation theory were calculated: the questionnaire-based 36-item Million Veteran Program-FI and 31-item Veterans Affairs-FI using claims data. We calculated Fried physical frailty using the self-reported, 3-item Study of Osteoporotic Fractures. Multivariable-adjusted Cox models examined the association of frailty by each score with primary (all-cause and CVD mortality) and secondary (myocardial infarction, stroke, and heart failure) outcomes. In 190 688 veterans (69±9 years, 94% male, 85% White), 33, 233 (17%) all-cause and 10 115 (5%) CVD deaths occurred. Using Million Veteran Program-FI, 29% were robust, 42% pre-frail, and 29% frail. Frailty prevalence increased by age group (27% in 50-59 to 42% in ≥90 years). Using the Million Veteran Program-FI, over 6±2 years, frail veterans had a higher hazard of all-cause (hazard ratio [HR], 3.05 [95% CI, 2.95-3.16]) and CVD mortality (HR, 3.65 [95% CI, 3.43-3.90]). Findings were concordant for the Veterans Affairs-FI and Study of Osteoporotic Fractures frailty definitions, and remained significant even among younger veterans aged 50-59 years.

CONCLUSIONS

Irrespective of frailty measure, frailty is associated with a higher risk of all-cause mortality and adverse CVD events. Further study of frailty in veterans aged <60 years old is warranted.

Frailty in acute coronary syndromes. A systematic review and narrative synthesis of frailty assessment tools and interventions from randomised controlled trials

AIM

We aimed to review all randomised controlled trial (RCT) data to explore optimal identification and treatment strategies of frail patients with Acute Coronary Syndromes (ACS).

METHODS

The protocol was preregistered (PROSPERO - CRD42021250235). We performed a systematic review including RCT's that 1; used at least one frailty assessment tool to assess frailty and its impact on outcomes in patients diagnosed with ACS and 2; used at least one intervention where change in frailty was measured in patients diagnosed with ACS. The Cochrane Central Register of Controlled Trials, MEDLINE and EMBASE were searched on the 1st April 2021 and updated on 4th July 2023. Owing to low search output results are presented as a narrative synthesis of available evidence.

RESULTS

A single RCT used a frailty assessment tool. A single RCT specifically targeted frailty with their intervention. This precluded further quantitative analysis. There was indication of selection bias against frail participants, and a signal of value for physical activity measurement in frail ACS patients. There was a high level of uncertainty and low level of robustness of this evidence.

CONCLUSIONS

Data from RCT's alone is inadequate in answering the reviews question. Future RCT's need to address ways to incorporate frail participants, whilst mitigating selection biases. Physical performance aspects of the frailty syndrome appear to be high yield modifiable targets that improve outcomes. Intervention trials should consider using change in frailty status as an outcome measure. Any trials that include frail participants should present data specifically attributable to this group.

Mechanical ventilation in acute myocardial infarction: Outcomes from a prospective audit at a cardiovascular hospital in Pakistan

BACKGROUND

This clinical audit aims to evaluate the clinical data regarding the management and outcomes of acute myocardial infarction (AMI) patients requiring mechanical ventilator (MV) support, along with identifying factors associated with prolonged MV support and 180-day mortality.

MATERIALS AND METHODS

In this study, we audited clinical data regarding management, in-hospital and short-term outcomes of adult patients with AMI required MV support. Patients with prolonged MV duration (>24h) and/or 180-day mortality were compared with their counterparts, and associated factors were identified. The binary logistic and Cox regression analyses were performed to determine the predictors of prolonged MV duration and 180-day mortality.

RESULTS

In a sample of 312 patients, 72.8% were male, and the mean age was 60.3±11.5 years. The median MV duration was 24 [24-48] hours, with 48.7% prolonged MV duration. The admission albumin level was found to be the independent predictor of prolonged MV duration with an adjusted OR of 0.42 [0.22-0.82]. Overall 7.4% were re-intubated, 6.7% needed renal replacement therapy, 17.6% required intra-aortic balloon pump (IABP) placement, and 16.7% required temporary pacemaker placement. The survival rate was 80.4% at the time of hospital discharge, 74.7% at 30-day, 71.2% at 90-day, and 68.6% at 180-day follow-up. Age, prolonged MV duration, and ejection fraction were found to be the independent predictors of cumulative 180-day mortality with adjusted HR of 1.04 [1.02-1.07], 1.02 [1.01-1.03], and 0.95 [0.92-0.98], respectively.

CONCLUSIONS

Prolonged ventilator duration has significant prognostic implications; hence, tailored early recognition of high-risk patients needing more aggressive care can improve the outcomes.

Performance of DAPT Score and ESC Criteria for Predicting Clinical Outcomes in Chinese Patients with Acute Coronary Syndrome

Purpose

The values of European Society of Cardiology (ESC) criteria and dual antiplatelet therapy (DAPT) score in the stratification of ischemic risk were assessed in this study.

Methods

A total of 489 patients with acute coronary syndrome who received DAPT at discharge between June 2020 and August 2020 were enrolled. The primary endpoint was the occurrence of major adverse cardiovascular events (MACE), which included recurrent ACS or unplanned revascularization, all-cause death, or ischemic stroke during a 27-month follow-up period.

Results

Patients with ESC-defined high-risk showed a significantly higher risk of MACE (HR 2.75, 95% CI 1.78-4.25), all-cause death (HR 2.49, 95% CI 1.14-5.43), and recurrent ACS or unplanned revascularization (HR 2.80, 95% CI 1.57-4.99) than those with ESC-defined low/medium-risk during follow-up. The results of landmark analysis showed that patients in the high-risk group had a significantly higher risk of MACE (HR 2.80,95 CI% 1.57-4.97), recurrent ACS or unplanned revascularization (HR 3.19,95 CI% 1.47-6.93) within one year, and a higher risk of MACE (HR 2.69,95 CI% 1.38-5.23) after one year. There was no significant difference in the incidence of MACE between patients with a DAPT score ≥2 and a DAPT score <2. The C-indices of ESC criteria and DAPT score for prediction of MACE were 0.63 (95% CI 0.57-0.70) and 0.54 (95% CI 0.48-0.61), respectively. The predictive value of ESC criteria for MACE was better than the DAPT score according to the DeLong test (z-statistic=2.30, P=0.020).

Conclusion

Patients with ESC-defined high-risk had a higher risk of MACE compared to those with ESC-defined low/medium-risk. The discriminant ability of the ESC criteria was better than the DAPT score for MACE. The ESC criteria demonstrated moderate discriminatory capacity of MACE in ACS patients treated with DAPT.

Physical Frailty May Predict 2-Year Prognosis in Elderly Patients With Acute Myocardial Infarction - A Report From the FLAGSHIP Study

BACKGROUND

Elderly patients with acute myocardial infarction (AMI) are a high-risk population for heart failure (HF), but the association between physical frailty and worsening prognosis, including HF development, has not been documented extensively.

METHODS AND RESULTS

As part of the FLAGSHIP study, we enrolled 524 patients aged ≥70 years hospitalized for AMI and capable of walking at discharge. Physical frailty was assessed using the FLAGSHIP frailty score. The primary outcome was a composite outcome of all-cause death and HF rehospitalization within 2 years after discharge. The secondary outcome was all-cause death and HF rehospitalization. After adjusting for confounders, physical frailty showed a significant association with an increased risk of the composite outcome (hazard ratio [HR]=2.09, 95% confidence interval [CI]: 1.03-4.22, P=0.040). The risk of HF rehospitalization increased with physical frailty, but the association was not statistically significant (HR=2.14, 95% CI: 0.84-5.44, P=0.110). Physical frailty was not associated with an increased risk of all-cause death (HR=1.45, 95% CI: 0.49-4.26, P=0.501).

CONCLUSIONS

The findings suggest that physical frailty assessment serves as a stratifying tool to identify high-risk populations for post-discharge clinical events among ambulant elderly patients with AMI.

Relationship Between Frailty, Sociodemographic and Clinical Characteristics, and Disease Severity of Older Adults With Acute Coronary Syndrome

This study aimed to evaluate the relationship between frailty, sociodemographic and clinical characteristics, and disease severity of older adults with acute coronary syndrome (ACS). A total of 57 hospitalized patients ≥60 years with ACS were assessed for frailty through the Tilburg Frailty Indicator. Disease severity was assessed by the Global Registry of Acute Coronary Events, by the maximum troponin level, and by the number of severely obstructed coronary arteries. The relationship between variables was assessed by Mann Whitney's test, Pearson's chi-square test, likelihood-ratio test, Fisher's exact test, or Student's t test. Analyses were bootstrapped to 1,000 to reduce potential sample bias. About 54.4% were frail. Frailty was associated with ethnicity (p = .02), marital status (p = .05), ischemic equivalents (p = .01), self-perceived health (p = .002), arthritis/rheumatism/arthrosis (p = .002), and number of severely obstructed coronary arteries (p = .05). These relationships can support intensified surveillance planning for the elderly at greatest risk, structuring of transitional care, appropriate nurse-coordinated secondary prevention delivery in primary care, and cardiac rehabilitation following ACS.

Impact of frailty on all-cause mortality and major bleeding in patients with atrial fibrillation: A meta-analysis

BACKGROUND

Conflicting results have been reported on the impact of frailty on adverse outcomes in patients with atrial fibrillation (AF). The aim of this meta-analysis was to evaluate the impact of frailty on death and major bleeding in patients with AF.

METHODS

We comprehensively searched PubMed and Embase databases until June 30, 2021 for the relevant studies that investigated the impact of frailty on all-cause mortality and major bleeding in AF patients. Pooled multivariable-adjusted risk ratio (RR) and 95% confidence intervals (CI) was estimated for the frail vs. nonfrail patients using a random-effect model.

RESULTS

Ten studies involving 97,413 patients with AF satisfied the inclusion criteria. The prevalence of frailty in patients with AF ranged between 5.9% and 89.5%. Meta-analysis indicated that frailty was associated with higher risk of all-cause mortality (RR 2.77; 95% CI 1.68-4.57) and major bleeding (RR 1.83; 95% CI 1.24-2.71). Subgroup analysis showed that the impact of frailty on all-cause mortality was consistently found in each subgroup.

CONCLUSION

Frailty independently predicts all-cause mortality and major bleeding in patients with AF. Determination of frailty status may play an important role in risk classification of AF patients. However. lack of standardized definition of frailty is the most important limitations of this meta-analysis.

Association between frailty and ischemic heart disease: a systematic review and meta-analysis

Background

Frailty is increasingly reported among older adults with cardiovascular diseases and it has been demonstrated to increase negative health outcomes and mortality. To date, no systematic review of the evidence is available regarding the association between frailty and ischemic heart disease (IHD). We performed a systematic review of literature and a meta-analysis to assess the association between frailty and IHD.

Methods

We selected all the studies that provided information on the association between frailty and IHD, regardless of the study setting, study design, or definition of IHD and frailty. PubMed, Web of Science and Embase were searched for relevant papers. Studies that adopted the Fried definition for frailty were included in the meta-analyses. For each measure of interest (proportions and estimates of associations), a meta-analysis was performed if at least three studies used the same definition of frailty. Pooled estimates were obtained through random effect models and Mantel-Haenszel weighting.

Results

Thirty-seven studies were included. Of these, 22 adopted the Fried criteria to define frailty and provided estimates of prevalence and therefore they were included in meta-analyses. The pooled prevalence of IHD in frail individuals was 17% (95% Confidence Interval [95%CI] 11–23%) and the pooled prevalence of frailty in individuals with IHD was 19% (95% CI 15–24%). The prevalence of frailty among IHD patients ranged from 4 to 61%. Insufficient data were found to assess longitudinal association between frailty and IHD.

Conclusions

Frailty is quite common in older persons with IHD. The identification of frailty among older adults with IHD should be considered relevant to provide individualized strategies of cardiovascular prevention and care. Further research should specifically explore the association between frailty and IHD and investigate the potential common biological ground.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12877-021-02304-9.

Clinical Characteristics and Long-Term Outcomes of Patients with Acute Coronary Syndrome During Travel

Cardiovascular disease is a major cause of death among travelers, but the clinical characteristics and clinical outcomes of patients who develop acute coronary syndrome (ACS) while traveling have not been assessed. We evaluated 2548 patients with ACS who underwent primary percutaneous coronary intervention (PCI) between 1999 and 2015 and compared the incidences of all-cause and cardiac death during follow-up between travelers and locals. We assessed 192 (7.5%) patients who developed ACS while traveling. These patients were younger and had a higher prevalence of ST-elevation myocardial infarction than local patients. During a median follow-up period of 5.3 years, 632 (24.8%) all-cause deaths were identified, including 310 cardiac deaths (12.2%). Kaplan-Meier analysis revealed that the cumulative incidence of all-cause death was significantly lower among the travelers than locals (P = 0.001, log-rank test). Multivariate Cox hazard analysis revealed that travel was significantly associated with a lower rate of all cause death (hazard ratio, 0.53; 95% confidence interval, 0.33-0.80; P = 0.002). Cardiac mortality did not significantly differ between travelers and locals (P = 0.29). Patients with ACS treated with primary PCI while traveling had more favorable long-term clinical outcomes than local patients. Appropriate initial treatments and secondary preventions might improve the prognosis of travelers.

Social Support and Mortality in Community-Dwelling Chinese Older Adults: The Mediating Role of Frailty

Purpose

Population ageing is posing an unprecedented challenge globally, necessitating a better understanding of modifiable factors and underlying pathways that could contribute to health and longevity in older age. We thus aim to investigate how the modifiable social support (and its various sources) is related to mortality among older adults, as well as whether and to what extent geriatric frailty plays a role in mediating the relationship.

Methods

We included 11,934 community-dwelling adults (≥65) from four waves of the Chinese Longitudinal Healthy Longevity Survey (2008–2018). Frailty was constructed by 44 health deficits, following a validated frailty index scale. Social support was measured using a sum score of three dimensions (family support, social service and social security) with 22 items. The outcome was all-cause mortality. Multivariate logistic or linear regression models were employed when appropriate to assess the associations among social support, frailty and mortality. Mediation analysis was applied to examine the role of frailty underlying the pathway between social support and mortality risk.

Results

A higher sum score of social support at baseline reduced mortality risk during the 10-year follow-up period (AOR=0.947, 95% CI=0.917~0.977). Amongst three sources of social support, family support and social security availability showed significantly protective effect against mortality, while social service revealed only non-significant effect. A higher level in the overall social support (β=−0.066, 95% CI=−0.113~-0.020) or family support (β=−0.121, 95% CI=−0.202~-0.039) was also significantly associated with decreased frailty. Meanwhile, frailty partially mediated the relationship of mortality with the overall social support and family support, where the proportion of mediation equaled to 17.1% and 20.5%, respectively.

Conclusion

Social support could be associated with reduced risks for frailty and mortality, and such protective influences are especially manifested in its family support component among Chinese older adults. Frailty functions as potential mediator underlying the association of mortality with social support and family support. Our findings indicate the importance of social support as an integral part of geriatric care and underline the potential benefits of frailty assessment and intervention.

Outcomes of hospitalized patients with COVID-19 according to level of frailty

Background

The complications from coronavirus disease 2019 (COVID-19) have been the subject of study in diverse scientific reports. However, many aspects that influence the prognosis of the disease are still unknown, such as frailty, which inherently reduces resistance to disease and makes people more vulnerable. This study aimed to explore the complications of COVID-19 in patients admitted to a third-level hospital and to evaluate the relationship between these complications and frailty.

Methods

An observational, descriptive, prospective study was performed in 2020. A sample of 254 patients from a database of 3,112 patients admitted to a high-level hospital in Madrid, Spain was analyzed. To assess frailty (independent variable) the Clinical Frailty Scale (CFS) was used. The outcome variables were sociodemographic and clinical, which included complications, length of stay, intensive care unit (ICU) admission and prognosis.

Results

A total of 13.39% of the patients were pre-frail and 17.32% were frail. Frail individuals had a shorter hospital stay, less ICU admission, higher mortality and delirium, with statistical significance.

Conclusion

Frailty assessment is a crucial approach in patients with COVID-19, given a higher mortality rate has been demonstrated amongst frail patients. The CFS could be a predictor of mortality in COVID-19.

Predictors of dropout from cohort study due to deterioration in health status, with focus on sarcopenia, locomotive syndrome, and frailty: From the Shiraniwa Elderly Cohort (Shiraniwa) study

BACKGROUND

Conditions of the elderly like sarcopenia, locomotive syndrome, and frailty have been attracting attention recently. However, the relationship of these 3 conditions and the difference in the magnitude of influence each has on deterioration in health status remain unclear. The purpose of this study was to investigate the prevalence and relationship of sarcopenia, locomotive syndrome, and frailty, and to clarify their influence on the dropout from cohort study due to deterioration in health status.

METHODS

The 1st survey of the Shiraniwa Elderly Cohort (Shiraniwa) study was conducted in 2016. We examined 409 participants (aged ≥ 65 years; 164 males, 245 females) and assessed sarcopenia, locomotive syndrome, and frailty. Those who could not attend the 2nd survey (2017) due to deterioration in health status were defined as the Dropout group. We investigated the predictors of Dropout using multiple logistic regression analysis.

RESULTS

The prevalence of sarcopenia, locomotive syndrome stage 2, and frailty were 4.4%, 40.1%, and 14.2%, respectively; 89.7% of participants with frailty were also diagnosed with locomotive syndrome stage 2. From the results of the 2nd survey, 46 people were classified into the Dropout group. Independent predictors of the Dropout were locomotive syndrome stage 2 (adjusted odds ratio [OR]: 2.42, 95% confidence interval [CI]: 1.11-5.31) and frailty (adjusted OR: 3.37, 95%CI: 1.56-7.30).

CONCLUSIONS

Locomotive syndrome stage 2 was the most common condition in the elderly, and most people with frailty also had locomotive syndrome stage 2. Locomotive syndrome stage 2 and frailty independently influenced the dropout from cohort study due to deterioration in health status. These results suggest that screening for locomotive syndrome is useful for early detection of the elderly with a risk of deterioration in health status, and screening for frailty may contribute to detecting the elderly with higher risk of deterioration in health status.

Prognostic value of serum albumin-to-creatinine ratio in patients with acute myocardial infarction: Results from the retrospective evaluation of acute chest pain study

The long-term association between serum albumin-to-creatinine ratio (sACR) and poor patient outcomes in acute myocardial infarction (AMI) remains unclear. This study aimed to determine whether sACR was a predictor of poor long-term survival in patients with AMI.This was a study of patients with AMI in the emergency department (ED) from the retrospective multicenter study for early evaluation of acute chest pain (REACP) study. The patients were categorized into tertiles (T1, T2, and T3) based on the admission sACR (0.445 and 0.584 g/μmol). Baseline sACR at admission to the ED was predictive of adverse outcomes. The primary outcome was all-cause mortality within the follow-up period. Cox proportional hazards models were performed to investigate the association between sACR and all-cause mortality in patients with AMI.A total of 2250 patients with AMI were enrolled, of whom 229 (10.2%) died within the median follow-up period of 10.7 (7.2-14.6) months. Patients with a lower sACR had higher all-cause mortality and adverse outcomes rates than patients with a higher sACR. Kaplan-Meier survival analysis showed that patients with a higher sACR had a higher cumulative survival rate (P < .001). Cox regression analysis showed that a decreased sACR was an independent predictor of all-cause mortality [T2 vs T1: hazard ratio (HR); 0.550, 95% confidence interval (95% CI), 0.348-0.867; P = .010 and T3 vs T1: HR, 0.305; 95% CI, 0.165-0.561; P < .001] and cardiac mortality (T2 vs T1: HR, 0.536; 95% CI, 0.332-0.866; P = .011 and T3 vs T1: HR, 0.309; 95% CI, 0.164-0.582, P < .001).The sACR at admission to ED was independently associated with adverse outcomes, indicating that baseline sACR was a useful biomarker to identify high-risk patients with AMI at an early phase in ED.

Does the Impact of Frailty on All-Cause Mortality in Older Persons Differ between Women and Men? A Meta-Analysis

OBJECTIVE

Sex-specific impact of frailty on all-cause mortality in older age population remains controversial. This meta-analysis aimed to evaluate the association between frailty and all-cause mortality in older age women vs men from the general population.

DESIGN

Meta-analysis.

SETTING AND PARTICIPANTS

PubMed and Embase databases were searched until March 25, 2020 for studies reporting sex-specific association of frailty phenotype or index with all-cause mortality among the older general population (age ≥60 years) in the same study.

MEASUREMENTS

All-cause mortality for the frail vs robust individuals.

RESULTS

Eight studies enrolling a total of 87, 000 individuals were identified. Using the frailty phenotype, the pooled risk ratio of all-cause mortality was 2.41 [95% confidence interval (CI) 2.07-2.80] for frail women and 2.94 (95% CI 2.12-4.09) for frail men. Using the frailty index, the pooled risk ratio of all-cause mortality was 3.23 (95% CI 2.16-4.83) for frail women and 2.63 (95% CI 2.33-2.98) for frail men. The pooled female-to-male ratio of relative risks was 0.93 (95% CI 0.76-1.13) for the frailty phenotype and 1.22 (95% CI 0.79-1.88) for the frailty index.

CONCLUSIONS AND IMPLICATIONS

Older men and women with frailty confer a higher risk of all-cause mortality in the general population from the same source. However, there is no significant sex difference in the association between phenotype or index and all-cause mortality.

Usefulness of the Simplified Frailty Scale in Predicting Risk of Readmission or Mortality in Elderly Patients Hospitalized with Cardiovascular Disease

The simplified frailty scale is a simple frailty assessment tool modified from Fried's phenotypic frailty criteria, which is easy to administer in hospitalized patients. The applicability of the simplified frailty scale to indicate prognosis in elderly hospitalized patients with cardiovascular disease (CVD) was examined.This cohort study was performed in 895 admitted patients ≥ 65 years (interquartile range, 71.0-81.0, 541 men) with CVD. Patients were classified as robust, prefrail, or frail based on the five components of the simplified frailty scale: weakness, slowness, exhaustion, low activity, and weight loss. The primary endpoint was the composite outcome of all-cause mortality and unplanned readmission for CVD.Patients positive for greater numbers of frailty components showed higher risk of all-cause mortality or unplanned CVD-related readmission (P for trend < 0.001). Classification as both frail (adjusted HR: 3.27, 95% confidence interval [CI]: 1.49-7.21, P = 0.003) and prefrail (adjusted HR: 2.19, 95% CI: 1.00-4.79, P = 0.049) independently predicted the composite endpoint compared with robust after adjusting for potential confounding factors. The inclusion of prefrail, frail, and number of components of frailty increased both continuous net reclassification improvement (0.113, P = 0.049; 0.426, P < 0.001; and 0.321, P < 0.001) and integrated discrimination improvement (0.007, P = 0.037; 0.009, P = 0.038; and 0.018, P = 0.002) for the composite endpoint.Higher scores on the simplified frailty scale were associated with increased risk of mortality or readmission in elderly patients hospitalized for CVD.

Frailty Confers High Mortality Risk across Different Populations: Evidence from an Overview of Systematic Reviews and Meta-Analyses

We performed an overview of systematic reviews and meta-analyses to summarize available data regarding the association between frailty and all-cause mortality. Medline, Embase, CINAHL, Web of Science, PsycINFO, and AMED (Allied and Complementary Medicine) databases were searched until February 2020 for meta-analyses examining the association between frailty and all-cause mortality. The AMSTAR2 checklist was used to evaluate methodological quality. Frailty exposure and the risk of all-cause mortality (hazard ratio [HR] or relative risk [RR]) were displayed in forest plots. We included 25 meta-analyses that pooled data from between 3 and 20 studies. The number of participants included in these meta-analyses ranged between <2000 and >500,000. Overall, 56%, 32%, and 12% of studies were rated as of moderate, low, and critically low quality, respectively. Frailty was associated with increased risk of all-cause mortality in 24/24 studies where the HR/RRs ranged from 1.35 [95% confidence interval (CI) 1.05-1.74] (patients with diabetes) to 7.95 [95% CI 4.88-12.96] (hospitalized patients). The median HR/RR across different meta-analyses was 1.98 (interquartile range 1.65-2.67). Pre-frailty was associated with a significantly increased risk of all-cause mortality in 7/7 studies with the HR/RR ranging from 1.09 to 3.65 (median 1.51, IQR 1.38-1.73). These data suggest that interventions to prevent frailty and pre-frailty are needed.