Frailty Is Associated with an Increased Risk of Major Adverse Cardiac Events in Patients with Stable Claudication

Longitudinal associations of polypharmacy and frailty with major cardiovascular events and mortality among more than half a million middle-aged participants of the UK Biobank

BACKGROUND

Studies of the associations of polypharmacy and frailty with adverse health outcomes in middle-aged adults are limited. Furthermore, a potentially stronger association of polypharmacy with adverse health outcomes in frail than in non-frail adults is of interest.

OBJECTIVE

To evaluate associations of frailty (assessed using a frailty index) and polypharmacy (defined as taking five or more drugs) with major cardiovascular events, cancer incidence, all-cause, cardiovascular disease-specific, and cancer-specific mortality.

METHODS

Cox proportional hazards regression models were used to analyze 501,548 participants of the UK Biobank cohort study aged 40-69 years who were followed up for an average of 12 years.

RESULTS

The prevalence of pre-frailty and frailty were 43.2 % and 2.3 %, respectively, and that of polypharmacy was 18.3 %. Although strongly associated with each other, frailty and polypharmacy were independently, statistically significantly associated with major cardiovascular events, cardiovascular disease-specific, and all-cause mortality. In addition, the hazard ratios of polypharmacy were stronger among (pre-)frail than non-frail study participants. No profound associations with cancer incidence and cancer mortality were observed. No sex and age differences were observed.

CONCLUSIONS

This large cohort study showed that polypharmacy and frailty are independent risk factors for major cardiovascular events, cardiovascular disease-specific and all-cause mortality in both middle-aged (40-64 years) and older people (≥ 65 years). In addition, the hazard ratios of polypharmacy were stronger among (pre-)frail than non-frail study participants. This underlines the need to avoid polypharmacy as far as possible not only in older but also in middle-aged subjects (40-64 years), especially if they are pre-frail or frail.

2024 ACC/AHA/AACVPR/APMA/ABC/SCAI/SVM/SVN/SVS/SIR/VESS Guideline for the Management of Lower Extremity Peripheral Artery Disease: A Report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines

AIM

The "2024 ACC/AHA/AACVPR/APMA/ABC/SCAI/SVM/SVN/SVS/SIR/VESS Guideline for the Management of Lower Extremity Peripheral Artery Disease" provides recommendations to guide clinicians in the treatment of patients with lower extremity peripheral artery disease across its multiple clinical presentation subsets (ie, asymptomatic, chronic symptomatic, chronic limb-threatening ischemia, and acute limb ischemia).

METHODS

A comprehensive literature search was conducted from October 2020 to June 2022, encompassing studies, reviews, and other evidence conducted on human subjects that was published in English from PubMed, EMBASE, the Cochrane Library, CINHL Complete, and other selected databases relevant to this guideline. Additional relevant studies, published through May 2023 during the peer review process, were also considered by the writing committee and added to the evidence tables where appropriate.

STRUCTURE

Recommendations from the "2016 AHA/ACC Guideline on the Management of Patients With Lower Extremity Peripheral Artery Disease" have been updated with new evidence to guide clinicians. In addition, new recommendations addressing comprehensive care for patients with peripheral artery disease have been developed.

2024 ACC/AHA/AACVPR/APMA/ABC/SCAI/SVM/SVN/SVS/SIR/VESS Guideline for the Management of Lower Extremity Peripheral Artery Disease: A Report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines

AIM

The "2024 ACC/AHA/AACVPR/APMA/ABC/SCAI/SVM/SVN/SVS/SIR/VESS Guideline for the Management of Lower Extremity Peripheral Artery Disease" provides recommendations to guide clinicians in the treatment of patients with lower extremity peripheral artery disease across its multiple clinical presentation subsets (ie, asymptomatic, chronic symptomatic, chronic limb-threatening ischemia, and acute limb ischemia).

METHODS

A comprehensive literature search was conducted from October 2020 to June 2022, encompassing studies, reviews, and other evidence conducted on human subjects that was published in English from PubMed, EMBASE, the Cochrane Library, CINHL Complete, and other selected databases relevant to this guideline. Additional relevant studies, published through May 2023 during the peer review process, were also considered by the writing committee and added to the evidence tables where appropriate.

STRUCTURE

Recommendations from the "2016 AHA/ACC Guideline on the Management of Patients With Lower Extremity Peripheral Artery Disease" have been updated with new evidence to guide clinicians. In addition, new recommendations addressing comprehensive care for patients with peripheral artery disease have been developed.

A systematic review of frailty assessment tools used in vascular surgery research

OBJECTIVE

Frailty is common in vascular patients and is recognized for its prognostic value. In the absence of consensus, a multitude of frailty assessment tools exist. This systematic review aimed to quantify the variety in these tools and describe their content and application to inform future research and clinical practice.

METHODS

Multiple cross-disciplinary electronic literature databases were searched from inception to August 2022. Studies describing frailty assessment in a vascular surgical population were eligible. Data extraction to a validated template included patient demographics, tool content, and analysis methods. A secondary systematic search for papers describing the psychometric properties of commonly used frailty tools was then performed.

RESULTS

Screening 5358 records identified 111 eligible studies, with an aggregate population of 5,418,236 patients. Forty-three differing frailty assessment tools were identified. One-third of these failed to assess frailty as a multidomain deficit and there was a reliance on assessing function and presence of comorbidity. Substantial methodological variability in data analysis and lack of methodological description was also identified. Published psychometric assessment was available for only 4 of the 10 most commonly used frailty tools. The Clinical Frailty Scale was the most studied and demonstrates good psychometric properties within a surgical population.

CONCLUSIONS

Substantial heterogeneity in frailty assessment is demonstrated, precluding meaningful comparisons of services and data pooling. A uniform approach to assessment is required to guide future frailty research. Based on the literature, we make the following recommendations: frailty should be considered a continuous construct and the reporting of frailty tools' application needs standardized. In the absence of consensus, the Clinical Frailty Scale is a validated tool with good psychometric properties that demonstrates usefulness in vascular surgery.

Footcare and peripheral arterial disease

Changes in the feet occur with age which can cause pain and other foot pathologies that can lead to falls, foot ulcers and amputation. Some older adults may have difficulty doing foot hygiene due to physical or mental decline such as body habitus, poor vision, arthritic problems to mention a few.1 The presence of PAD creates an increased risk of foot ulcers, leg/foot infection and lower extremity amputation, especially in diabetic patients. PAD is often asymptomatic;2 however PAD prevalence increases with age, the majority of which occurs over age 65.3 African-American and Native Americans have approximately twice the prevalence of PAD than that of non-Hispanic Whites.4 There is a 40% rate of death at 5 years following the development of a foot ulcer in PAD patients.5 Foot ulcers require increased medical office visits, increased resource utilization, increased patient anxiety/depression and reduced quality of life (QOL).6 However, routine foot examinations and educating patients and their families in proper footcare can detect common foot problems, uncover functional decline and PAD, and prevent falls. In patients at-risk for foot ulcers, a yearly comprehensive foot evaluation can prevent foot ulcers, foot pain, and lower extremity amputation. Evaluation and early recognition of PAD can reduce morbidity and mortality.6,8,13.

Preoperative Assessment of Patients with Vascular Disease

Patients with vascular disease represent a particularly high-risk surgical population. Many of the comorbidities that contribute to their vascular presentation impact a number of vascular beds or other organ systems. As a result, these patients have the highest rates of cardiac and pulmonary complications among patients with noncardiac surgery. The vascular surgeon is in a unique position to help evaluate and treat many of these conditions to not only reduce the perioperative risk but also to improve the patient's overall health. This article presents a comprehensive review of the common preoperative evaluations that have a high impact on patients with vascular disease.

The association between frailty and incident cardiovascular disease events in community-dwelling healthy older adults

Study objective

This study examined the association between frailty and incident cardiovascular disease (CVD) events, major adverse cardiovascular events (MACE), and CVD-related mortality.

Design

Longitudinal cohort study.

Setting

The ASPirin in Reducing Events in the Elderly (ASPREE) clinical trial in Australia and the United States.

Participants

19,114 community-dwelling older adults (median age 74.0 years; 56.4 % females).

Interventions

Pre-frailty and frailty were assessed using a modified Fried phenotype and a deficit accumulation Frailty Index (FI) at baseline.

Main outcome measures

CVD was defined as a composite of CVD death, non-fatal myocardial infarction, non-fatal stroke, and hospitalization for heart failure; MACE included all except heart failure. Cox proportional hazards regression was used to analyze the association between frailty and CVD outcomes over a median follow-up of 4.7 years.

Results

Baseline pre-frail and frail groups had a higher risk of incident CVD events (Hazard Ratio (HR): 1.31; 95 % Confidence Interval (CI): 1.14-1.50 for pre-frail and HR: 1.63; 95 % CI: 1.15-2.32 for frail) and MACE (pre-frail HR: 1.26; 95 % CI: 1.08-1.47 and frail HR: 1.51; 95 % CI: 1.00-2.29) than non-frail participants according to Fried phenotype after adjusting for traditional CVD risk factors. Effect sizes were similar or larger when frailty was assessed with FI; similar results for men and women.

Conclusion

Frailty increases the likelihood of developing CVD, including MACE, in community-dwelling older men and women without prior CVD events. Screening for frailty using Fried or FI method could help identify community-dwelling older adults without prior CVD events who are more likely to develop CVD, including MACE, and may facilitate targeted preventive measures to reduce their risk.

Use of the 11-Item Modified Frailty Index to Determine Accurate Prognosis and Revascularization Strategy in Patients Undergoing Vascular Bypass Surgery for Intermittent Claudication

BACKGROUND

In cases of intermittent claudication (IC) where traditionally noninvasive management yields unsatisfactory results, revascularization strategy in IC patients is generally decided based on anatomical considerations and the availability of a saphenous vein graft. Life expectancy should also be considered. This study aimed to investigate the relationship between the 11-item modified frailty index (mFI-11) and the overall survival (OS) in patients with IC who underwent vascular bypass surgery to facilitate revascularization strategy selection.

METHODS

We reviewed the records of 144 consecutive patients (153 lower limbs) who underwent infrainguinal bypass for IC between 2011 and 2020. Patients were divided into 2 groups based on their mFI-11 score: high frailty (H), mFI score >0.3; and low frailty (L), mFI score ≤0.3. The OS was compared among the 2 groups. Rates of graft patency and freedom from major adverse limb event (ffMALE) were also determined and compared.

RESULTS

Five-year OS in the L and H groups was 92% and 55% (P < 0.001). Multivariate analysis showed that mFI, age, and end-stage renal disease were independent predictors of OS. Five-year rates of primary and secondary patency and ffMALE for vein grafts were 81%, 91%, and 94%, respectively; those for prosthetic grafts were 65%, 80%, and 84%, respectively; the differences were not significant.

CONCLUSIONS

The mFI-11 was a helpful tool in predicting OS for patients with IC who underwent vascular bypass surgery. Those with H should not undergo open revascularization; however, for IC patients who have either not responded to a regimen of exercise and medication, or have specifically requested a more aggressive approach, obtaining a good score in frailty assessment is useful in determining whether or not bypass surgery would be a viable option.

Aortic Stiffness: A Major Risk Factor for Multimorbidity in the Elderly

Multimorbidity, the coexistence of multiple health conditions in an individual, has emerged as one of the greatest challenges facing health services, and this crisis is partly driven by the aging population. Aging is associated with increased aortic stiffness (AoStiff), which in turn is linked with several morbidities frequently affecting and having disastrous consequences for the elderly. These include hypertension, ischemic heart disease, heart failure, atrial fibrillation, chronic kidney disease, anemia, ischemic stroke, and dementia. Two or more of these disorders (multimorbidity) often coexist in the same elderly patient and the specific multimorbidity pattern depends on several factors including sex, ethnicity, common morbidity routes, morbidity interactions, and genomics. Regular exercise, salt restriction, statins in patients at high atherosclerotic risk, and stringent blood pressure control are interventions that delay progression of AoStiff and most likely decrease multimorbidity in the elderly.

Prevalence of frailty in patients with lower extremity peripheral arterial disease: A systematic review and meta-analysis

BACKGROUND

Increasing studies have reported on the prevalence of frailty in patients with peripheral artery disease (PAD). The aim of this systematic review and meta-analysis was to estimate the pooled prevalence of frailty in patients with lower extremity PAD.

METHODS

Two authors systematically searched PubMed and Embase databases from their inception to August 8, 2022. Original articles that reported the prevalence of frailty in patients with lower extremity PAD were included. The prevalence of frailty in patients with lower extremity PAD was pooled using a random-effect model. Meta-regression, subgroup, and sensitivity analyses were conducted to explore the heterogeneity.

RESULTS

Eighteen studies reported on 17 articles involving 1,726,343 patients with lower extremity PAD were identified. The pooled prevalence of frailty in patients with lower extremity PAD was 49 % (95 % confidence interval [CI] 37-61 %), with significant heterogeneity between studies (I ² = 100 %, p < 0.001). Multivariable meta-regression showed that only the severity of PAD (coefficient 0.270; 95 % CI 0.017-0.523, p = 0.039) was significantly associated with the heterogeneity. In subgroup analysis, the pooled prevalence of frailty was higher in critical limb ischemia or chronic limb-threatening ischemia (54 %) than all PAD (48 %); the pooled prevalence of frailty was 64 %, 51 %, and 54 % for Modified Frailty Index-5, Modified Frailty Index-11, and Clinical Frailty Scale, respectively. The pooled prevalence of frailty appeared to be lower in male (39 %) than the female patients (47 %).

CONCLUSIONS

The prevalence of frailty was higher in patients with lower extremity PAD, suggesting frailty is a common condition. This finding highlights the significance of assessing frailty in patients with lower extremity PAD.

Plasma Gut Microbe-Derived Metabolites Associated with Peripheral Artery Disease and Major Adverse Cardiac Events

Cardiovascular diseases are associated with gut dysbiosis, but the role of microbe-derived metabolites as biomarkers or modulators of cardiovascular disease are not well understood. This is a targeted metabolomics study to investigate the association of nine microbe-derived metabolites with lower extremity peripheral artery disease (PAD), a form of atherosclerosis, and major adverse cardiac events (MACE). The study cohort consists of individuals with intermittent claudication and ankle-brachial index (ABI) < 0.9 (N = 119) and controls without clinically-apparent atherosclerosis (N = 37). The primary endpoint was MACE, a composite endpoint of myocardial infarction, coronary revascularization, stroke, transient ischemic attack, or cardiac-related death. Plasma metabolite concentrations differed significantly between the PAD and control groups. After adjustment for traditional atherosclerosis risk factors, kynurenine, hippuric acid, indole-3-propionic acid (IPA), and indole-3-aldehyde (I3A) concentrations were negatively associated with PAD, whereas indoxyl sulfate and 3-hydroxyanthranilic acid were positively associated. Hippuric acid, IPA, and I3A correlated with ABI, a surrogate for atherosclerotic disease burden. Those in the highest I3A concentration quartile had significantly improved freedom from MACE during follow-up compared to those in the lowest quartile. This study identifies specific indole- and phenyl-derived species impacted by gut microbial metabolic pathways that could represent novel microbiome-related biomarkers of PAD.

Impact of frailty on all-cause mortality or major amputation in patients with lower extremity peripheral artery disease: A meta-analysis

BACKGROUND

Frailty has been increasingly identified as a risk factor of adverse outcomes in vascular disease. However, its impact on the survival and amputation in patients with lower extremity peripheral artery disease (PAD) remains controversial. This meta-analysis aimed to examine the value of frailty in predicting all-cause mortality or major amputation in patients with lower extremity PAD.

METHODS

PubMed, Embase, Web of Sciences, and Scopus databases (up to April 7, 2022) were comprehensively searched to identify relevant studies that investigated the association between frailty and all-cause mortality or major amputation in patients with lower extremity PAD. The impact of frailty on adverse outcomes was summarized by pooling the fully adjusted hazard ratio (HR) with 95% confidence intervals (CI) using a random effect (DerSimonian-Laird) model.

RESULTS

Seven studies reporting on eight articles that involved 122,892 patients were included. The prevalence of frailty ranged from 42% to 80% based on the frailty tool used. Meta-analysis showed that frailty was associated with an increased risk of 30-day all-cause mortality (HR 2.11; 95% CI 1.41-3.15; I² =47.6%, p = 0.148, Tau-squared=0.058) and long-term all-cause mortality (HR 1.86; 95% CI 1.25-2.76; I² =76.1%, p = 0.002, Tau-squared=0.118). However, no clear association was observed between frailty and major amputation (HR 1.07; 95% CI 0.83-1.36; I² =23.0%, p = 0.273, Tau-squared=0.019).

CONCLUSION

Frailty independently predicts short and long-term all-cause mortality but not major amputation in patients with lower extremity PAD. Frailty status may play an important role in risk stratification of lower extremity PAD.

Association of wound, ischemia, and foot infection clinical stage with frailty and malnutrition in chronic limb-threatening ischemia patients undergoing endovascular intervention

OBJECTIVE

The Wound, Ischemia, and foot Infection (WIfI) clinical stage has been thought to have a prognostic value in Chronic limb-threatening ischemia (CLTI) patients, and frailty and nutritional status appear to represent pivotal factor affecting prognosis among CLTI patients. The purpose of this study was to examine clinical factors (including frailty and nutritional status) relevant to WIfI clinical stage.

METHODS

This retrospective study investigated 200 consecutive CLTI patients. We individually assessed WIfI clinical stage, frailty according to the Clinical Frailty Scale (CFS) score, and malnutrition according to Geriatric Nutritional Risk Index (GNRI). We then compared mortality after endovascular intervention between a WIfI stage 1, 2 group and a stage 3, 4 group, and investigated associations between baseline characteristics (including CFS and GNRI) and WIfI clinical stage.

RESULTS

Among 200 patients, 123 patients (62%) showed WIfI stage 1 or 2, and the remaining 77 patients (38%) had WIfI stage 3 or 4. CFS score was significantly higher in the WIfI stage 3, 4 group [median 6.0, interquartile range (IQR) 5.5-7.0] compared with the WIfI stage 1, 2 group (median 5.0, IQR 4.0-6.0, p < 0.001), and GNRI was significantly lower in the WIfI stage 3, 4 group (median 88, IQR 80-97) than in the WIfI stage 1, 2 (median 103, IQR 94-111, p < 0.001). Forty patients (20%) died after endovascular intervention. Incidences of all-cause and cardiac deaths were higher in the WIfI stage 3, 4 group than in the WIfI stage 1, 2 group (27% vs. 15%, p = 0.047 and 12% vs. 3%, p = 0.040, respectively). Kaplan-Meier analysis showed a significantly lower survival rate in the WIfI stage 3, 4 group than in the WIfI stage 1, 2 group (p = 0.002 by log-rank test). Multivariate logistic regression analysis using relevant factors from univariate analysis showed CFS score [odds ratio (OR) 2.06, 95% confidence interval (CI) 1.41-3.13, p < 0.001), diabetes mellitus (OR 3.17, 95%CI 1.17-8.61, p = 0.023) and GNRI (OR 0.93, 95%CI 0.89-0.97, p = 0.002) significantly associated with WIfI stage 3 or 4. In addition, multivariate ordinal logistic regression analysis for WIfI clinical stage showed CFS score (OR 1.43, 95%CI 1.09-1.89, p = 0.011), diabetes mellitus (OR 1.77, 95%CI 1.26-2.54, p < 0.001), and high-sensitivity C-reactive protein (OR 1.14, 95%CI 1.02-1.28, p = 0.041) were positively associated with WIfI clinical stage, and GNRI correlated negatively with WIfI clinical stage (OR 0.95, 95%CI 0.91-0.97, p < 0.001).

CONCLUSIONS

These results indicate that CLTI patients with high WIfI clinical stage may be more frail and malnourished, and be associated with poor prognosis after endovascular intervention.

Outcome Analysis Using the Modified Frailty Index-5 in Patients With Complex Aortoiliac Disease

OBJECTIVES

Vascular surgery patients commonly have several comorbidities that cumulatively lead to a frailty status. The cumulative comorbidities disproportionately increase the risk of adverse events and are also associated with worsened long-term prognosis. In recent years, several tools have been elaborated with the objective of quantifying a patient's frailty. One of them is the modified frailty index-5 (mFI-5), a simplified and easy to use index. There is scarce data regarding its value as a prognostic factor in aortoiliac occlusive disease. The aim of this work is to validate mFI-5 as a potential postoperative prognostic indicator in this population.

METHODS

From January 2013 to January 2020, 109 patients who underwent elective revascularizations, either endovascular or open surgery, having Trans-Atlantic Inter-Society Consensus II type D aortoiliac lesions in a tertiary and a regional hospital were selected from a prospective vascular registry. Demographic data was collected including diabetes mellitus, chronic heart failure, chronic obstructive pulmonary disease, arterial hypertension requiring medication and functional status. The 30-d and subsequent long-term surveillance outcomes were also collected including major adverse cardiovascular events (MACE), major adverse limb events (MALE) and all-cause mortality were assessed in the 30-d post-procedure and in the subsequent long-term surveillance period. The mFI-5 was applied to this population to evaluate the prognostic impact of this frailty marker on mortality and morbidity.

RESULTS

In the long-term follow-up, mFI-5 was significantly associated with MACE (hazard ratio [HR] 2.469; 95% confidence interval [CI]: 1.267-4.811; P = .008) and all-cause mortality (HR 2.585; 95% CI: 1.270-5.260; P = .009). However, there was no significant association with 30-day outcomes. Along with the presence of chronic kidney disease, mFI-5 was the prognostic factor better able of predicting MACE. No prognostic value was found regarding short-term outcomes.

CONCLUSION

The mFI-5 index may have a role in predicting long term outcomes, namely MACE and all-cause mortality, in the subset of patients with extensive aortoiliac occlusive disease. Its ease of use can foster its application in risk stratification and contribute for the decision-making process.

Frailty and cardiovascular outcomes in the National Health and Aging Trends Study

AIMS

Physical frailty is a commonly encountered geriatric syndrome among older adults without coronary heart disease (CHD). The impact of frailty on the incidence of long-term cardiovascular outcomes is not known.We aimed to evaluate the long-term association of frailty, measured by the Fried frailty phenotype, with all-cause-mortality and MACE among older adults without a history of CHD at baseline in the National Health and Aging Trends Study.

METHODS AND RESULTS

We used the National Health and Aging Trends Study, a prospective cohort study linked to a Medicare sample. Participants with a prior history of CHD were excluded. Frailty was measured during the baseline visit using the Fried physical frailty phenotype. Cardiovascular outcomes were assessed during a 6-year follow-up.Of the 4656 study participants, 3259 (70%) had no history of CHD 1 year prior to their baseline visit. Compared to those without frailty, subjects with frailty were older (mean age 82.1 vs. 75.1 years, P < 0.001), more likely to be female (68.3% vs. 54.9%, P < 0.001), and belong to an ethnic minority. The prevalence of hypertension, falls, disability, anxiety/depression, and multimorbidity was much higher in the frail and pre-frail than the non-frail participants. In a Cox time-to-event multivariable model and during 6-year follow-up, the incidences of death and of each individual cardiovascular outcomes were all significantly higher in the frail than in the non-frail patients including major adverse cardiovascular event (MACE) [hazard ratio (HR) 1.77, 95% confidence interval (CI) 1.53, 2.06], death (HR 2.70, 95% CI 2.16, 3.38), acute myocardial infarction (HR 1.95, 95% CI 1.31, 2.90), stroke (HR 1.71, 95% CI 1.34, 2.17), peripheral vascular disease (HR 1.80, 95% CI 1.44, 2.27), and coronary artery disease (HR 1.35, 95% CI 1.11, 1.65).

CONCLUSION

In patients without CHD, frailty is a risk factor for the development of MACEs. Efforts to identify frailty in patients without CHD and interventions to limit or reverse frailty status are needed and, if successful, may limit subsequent adverse cardiovascular events.

Frailty as a predictor of major adverse cardiac and cerebrovascular events after endovascular aortic aneurysm repair

OBJECTIVE

To evaluate the effect of frailty assessed by the modified Frailty Index (mFI) on major adverse cardiac and cerebrovascular events (MACCE) in the elderly patients after endovascular aortic aneurysm repair (EVAR).

METHODS

This was a retrospective cohort study of elderly patients who underwent EVAR in a tertiary hospital. The main exposure was frailty status assessed by the mFI. The primary outcomes were 30-day and long-term MACCE. The predictive ability of the mFI was compared with the Revised Cardiac Risk Index (RCRI) using net reclassification improvement (NRI) and integrated discrimination improvement (IDI) statistics.

RESULTS

Of 749 participants, 134 (17.89%) were identified as frail and 185 (24.70%) as prefrail. Thirteen patients (1.74%) were lost in follow-up after surgery, and the median length of follow-up was 32.00 months (range, 15.00-59.25 months). Frailty was associated with a significantly increased risk of 30-day MACCE (adjusted odds ratio OR, 14.53; 95% confidence interval [CI], 4.59-46.04; P < .0001) and longer intensive care unit stay (adjusted odds ratio, 2.43; 95% CI, 1.17-5.07; P = .0176). As for long-term outcomes, both frailty and prefrailty were associated significantly increased risks of MACCE after EVAR (prefrail: adjusted hazard ratio [HR] 1.71; 95% CI, 1.12-2.61; frail: adjusted HR, 3.37; 95% CI, 1.86-6.10). When considering death as a competing risk, we also observed a significant association between frailty and cardiac and cerebrovascular events (adjusted HR, 2.95; 95% CI, 1.06-8.15). In addition, frailty was associated with a significantly increased risk of all-cause mortality (adjusted HR, 1.93; 95% CI, 1.28-2.90). Compared with the RCRI, the mFI had better discrimination in predicting 30-day MACCE (IDI: 0.225; 95% CI, 0.018-0.431; P = .033; NRI: 0.225; 95% CI, 0.023-0.427; P = .029) and long-term MACCE (IDI: 0.056; 95% CI, 0.018-0.128; P = .013; NRI: 0.237; 95% CI, 0.136-0.359; P < .001).

CONCLUSIONS

Frailty assessed by the mFI may serve as a useful predictor of both short-term and long-term MACCE in elderly patients after EVAR, with improved discrimination and reclassification abilities compared with the RCRI.

The Accumulating Deficits Model for Postoperative Mortality and Readmissions: Comparison of four Methods Over Multiple Calendar Year Cohorts: Brief Title: Stability of the Modified Frailty Index

OBJECTIVE

To assess four measures of the accumulating deficits model of frailty for postoperative mortality and readmissions including their stability over time.

BACKGROUND

Frailty has been assessed by multiple methods. It is unclear whether variation in how frailty is measured is important and would be stable over time.

METHODS

Rockwood's 57-item frailty index (FI) was mapped onto 14,568 ICD9 diagnosis codes from Healthcare Cost and Utilization Project State Inpatient Database for the state of Florida (HCUP-SID-FL) for calendar years 2011-2015, inclusive, with 962 ICD9 codes matching onto 42 items. This became the modified frailty index (mFI) used. Three measures of the mFI were differentiated: the number of admission diagnoses, number of chronic conditions upon admission, and number of increased deficits accumulated during the admission. The Charlson Co-Morbidity Index was a fourth measure of frailty. The mFI of patients who survived or died and were readmitted or not were compared.

RESULTS

Across all years, 4,796,006 patient observations were compared to the number of diagnoses matched on the 42 items of the mFI. The median mFI scores for each method was statistically significantly higher for patients who died compared those that survived and for patients readmitted compared to patients not re-admitted for all years. There was little-to-no variation in the year to year median mFI scores.

CONCLUSIONS

The four methods of calculating frailty performed similarly and were stable. The actual method of determining the accumulated deficits may not be as important as enumerating their number.

Association Between Wearable Device-Based Measures of Physical Frailty and Major Adverse Events Following Lower Extremity Revascularization

IMPORTANCE

Physical frailty is a key risk factor associated with higher rates of major adverse events (MAEs) after surgery. Assessing physical frailty is often challenging among patients with chronic limb-threatening ischemia (CLTI) who are often unable to perform gait-based assessments because of the presence of plantar wounds.

OBJECTIVE

To test a frailty meter (FM) that does not rely on gait to determine the risk of occurrence of MAEs after revascularization for patients with CLTI.

DESIGN, SETTING, AND PARTICIPANTS

This cohort study included 184 consecutively recruited patients with CLTI at 2 tertiary care centers. After 32 individuals were excluded, 152 participants were included in the study. Data collection was conducted between May 2018 and June 2019.

EXPOSURES

Physical frailty measurement within 1 week before limb revascularization and incidence of MAEs for as long as 1 month after surgery.

MAIN OUTCOMES AND MEASURES

The FM works by quantifying weakness, slowness, rigidity, and exhaustion during a 20-second repetitive elbow flexion-extension exercise using a wrist-worn sensor. The FM generates a frailty index (FI) ranging from 0 to 1; higher values indicate progressively greater severity of physical frailty.

RESULTS

Of 152 eligible participants (mean [SD] age, 67.0 [11.8] years; 59 [38.8%] women), 119 (78.2%) were unable to perform the gait test, while all could perform the FM test. Overall, 53 (34.9%), 58 (38.1%), and 41 (27.0%) were classified as robust (FI <0.20), prefrail (FI ≥0.20 to <0.35), or frail (FI ≥0.35), respectively. Within 30 days after surgery, 24 (15.7%) developed MAEs, either major adverse cardiovascular events (MACE; 8 [5.2%]) or major adverse limb events (MALE; 16 [10.5%]). Baseline demographic characteristics were not significantly different between frailty groups. In contrast, the FI was approximately 30% higher in the group that developed MAEs (mean [SD] score, 0.36 [0.14]) than those who were MAE free (mean [SD] score, 0.26 [0.13]; P = .001), with observed MAE rates of 4 patients (7.5%), 7 patients (12.1%), and 13 patients (31.7%) in the robust, prefrail and frail groups, respectively (P = .004). The FI distinguished individuals who developed MACE and MALE from those who were MAE free (MACE: mean [SD] FI score, 0.38 [0.16]; P = .03; MALE: mean [SD] FI score, 0.35 [0.13]; P = .004) after adjusting by body mass index.

CONCLUSIONS AND RELEVANCE

In this cohort study, measuring physical frailty using a wrist-worn sensor during a short upper extremity test was a practical method for stratifying the risk of MAEs following revascularization for CLTI when the administration of gait-based tests is often challenging.

Frailty Factors and Outcomes in Vascular Surgery Patients: A Systematic Review and Meta-analysis

OBJECTIVE

To describe and critique tools used to assess frailty in vascular surgery patients, and investigate its associations with patient factors and outcomes.

BACKGROUND

Increasing evidence shows negative impacts of frailty on outcomes in surgical patients, but little investigation of its associations with patient factors has been undertaken.

METHODS

Systematic review and meta-analysis of studies reporting frailty in vascular surgery patients (PROSPERO registration: CRD42018116253) searching Medline, Embase, CINAHL, PsycINFO, and Scopus. Quality of studies was assessed using Newcastle-Ottawa scores (NOS) and quality of evidence using Grading of Recommendations Assessment, Development, and Evaluation criteria. Associations of frailty with patient factors were investigated by difference in means (MD) or expressed as risk ratios (RRs), and associations with outcomes expressed as odds ratios (ORs) or hazard ratios (HRs). Data were pooled using random-effects models.

RESULTS

Fifty-three studies were included in the review and only 8 (15%) were both good quality (NOS ≥ 7) and used a well-validated frailty measure. Eighteen studies (62,976 patients) provided data for the meta-analysis. Frailty was associated with increased age [MD 4.05 years; 95% confidence interval (CI) 3.35, 4.75], female sex (RR 1.32; 95% CI 1.14, 1.54), and lower body mass index (MD -1.81; 95% CI -2.94, -0.68). Frailty was associated with 30-day mortality [adjusted OR (AOR) 2.77; 95% CI 2.01-3.81), postoperative complications (AOR 2.16; 95% CI 1.55, 3.02), and long-term mortality (HR 1.85; 95% CI 1.31, 2.62). Sarcopenia was not associated with any outcomes.

CONCLUSION

Frailty, but not sarcopenia, is associated with worse outcomes in vascular surgery patients. Well-validated frailty assessment tools should be preferred clinically, and in future research.

Palliative Care and End-of-Life Considerations for the Frail Patient

Patients with frailty experience substantial physical and emotional distress related to their condition and face increased morbidity and mortality compared with their nonfrail peers. Palliative care is an interdisciplinary medical specialty focused on improving quality of life for patients with serious illness, including those with frailty, throughout their disease course. Anesthesiology providers will frequently encounter frail patients in the perioperative period and in the intensive care unit (ICU) and can contribute to improving the quality of life for these patients through the provision of palliative care. We highlight the opportunities to incorporate primary palliative care, including basic symptom management and straightforward goals-of-care discussions, provided by the primary clinicians, and when necessary, timely consultation by a specialty palliative care team to assist with complex symptom management and goals-of-care discussions in the face of team and/or family conflict. In this review, we apply the principles of palliative care to patients with frailty and synthesize the evidence regarding methods to integrate palliative care into the perioperative and ICU settings.

Predictors of Need for First and Recurrent Emergency Medical Service Transport to Emergency Department after Dialysis Initiation

Background: Dialysis patients are frequently transported to the emergency department (ED) by Emergency Medical Services (EMS) due to acute and severe illness. However, little is known about predictors of first and recurrent transport to the ED (EMS-ED), based on characteristics at the time of dialysis initiation.Methods: We analyzed a cohort of adult (≥18 years) patients affiliated with a large quaternary care center who initiated chronic dialysis from 2009 to 2013 (last follow-up: 2015). Data on patient characteristics at the time of dialysis initiation were linked to regional EMS data. Candidate predictors of first and recurrent EMS-ED transport included comorbid conditions, dialysis characteristics and frailty severity (using the first version of the clinical frailty scale score; CFS). Time to first EMS-ED was analyzed using a multivariable sub-hazards regression model accounting for competing events (transplantation or death). Time to recurrent EMS-ED was analyzed using the Anderson-Gill counting approach, accounting for competing risks.Results: A total of 455 patients were included in the study, 243 (53%) had 1+ EMS-ED events, 90 (20%) never required an EMS-ED at last follow-up, and 69 (15%) and 53 (12%) experienced transplant or death as their first event, respectively. The mean age of the cohort was 62 ± 15 years, 89% were Caucasian, and 35% were female sex. Patients were highly comorbid and 97/381 (25.5%) with available data on frailty severity had a CFS score of ≥5, inclusive of CFS scores ranging from mildly to severely frail. After adjustment, a CFS score of ≥5 (relative to 1-2) was associated with a > 2-fold increase in the risk of first EMS-ED (subdistribution relative hazard; SHR 2.28, 95% confidence interval; CI 1.30-3.98). A history of peripheral vascular disease (SHR 1.43, 95% CI 1.00-2.03) and rheumatologic disease (SHR 1.84, 95% CI 1.00-3.38) was also associated with first EMS-ED. Frailty severity was the only factor associated with recurrent EMS-ED.Conclusion: Patients are at a high risk of EMS-ED after dialysis initiation. Frailty severity (at the time of dialysis initiation) is a strong predictor of first and recurrent EMS-ED and this may be important to guide informed decision making and resource planning for dialysis patients who require EMS.

C2 Fractures in the Elderly: Single-Center Evaluation of Risk Factors for Mortality

Study Design

Retrospective cohort study.

Purpose

The aim of this study was to identify features associated with increased mortality risk in traumatic C2 fractures in the elderly, including measures of comorbidity and frailty.

Overview of Literature

C2 fractures in the elderly are of increasing relevance in the setting of an aging global population and have a high mortality rate. Previous analyzes of risk factors for mortality have not included the measures of comorbidity and/or frailty, and no local data have been reported to date.

Methods

This study comprises a retrospective review of 70 patients of age >65 years at Waikato Hospital, New Zealand with traumatic C2 fractures identified on computed tomography between 2010 and 2016. Demographic details, medical history, laboratory results on admission, mechanism of injury, and neurological status on presentation were recorded. Medical comorbidities were also detailed allowing calculation of the Charlson Comorbidity Index (CCI) and the modified Frailty Index (mFI).

Results

The most common mechanism of injury was a fall from standing height (n=52, 74.3%). Mortality rates were 14.3% (n=10) at day 30, and 35.7% (n=25) at 1 year. Bivariate analysis showed that both CCI and mFI correlated with 1-year mortality rates. Reduced albumin and hemoglobin levels were also associated with 30-day and 1-year mortality rates. Forward stepwise logistic regression models determined CCI and low hemoglobin as predictors of mortality within 30 days, whereas CCI, low albumin, increased age, and female gender predicted mortality at 1 year.

Conclusions

The CCI was a useful tool for predicting mortality at 1 year in the patient cohort. Other variables, including common laboratory markers, can also be used for risk stratification, to initiate timely multidisciplinary management, and prognostic counseling for patients and family members.

Validity of the Mini-Nutritional Assessment Scale for Evaluating Frailty Status in Older Adults

OBJECTIVES

Comprehensive Geriatric Assessment (CGA) may not be performed in clinical practice as it takes too much time and requires special training. The Mini-Nutritional Assessment (MNA) is widely used to assess nutritional status in older adults. We aimed to determine whether or not the MNA can estimate frailty status defined by the Fried criteria.

SETTING AND PARTICIPANTS

Six hundred two outpatients aged 65 years or older who underwent the CGA were included the study.

MEASURES

Frailty status was defined by 5 dimensions including shrinking, exhaustion, low levels of activity, weakness, and slowness: 0 for robust, 1-2 for prefrail, and 3-5 for frail. MNA was performed in all participants even if their MNA-Short Form scores were ≥12.

RESULTS

Of the 602 outpatients, of whom the mean age was 74.2 ± 8.2 years, 190 participants (31.6%) were considered frail and 218 (36.2%) prefrail. Internal consistency of the MNA had a Cronbach-alpha of 0.701. Interclass correlation coefficient for the test-retest reliability was found as 0.697. MNA with a cut-off point of 22.5 had a sensitivity of 72.1% and a specificity of 91.2% to detect frail participants. MNA with a cut-off point of 25.5 had a sensitivity of 66.9% and a specificity of 85.4% to detect prefrailty. For the estimation of frailty and prefrailty, the area under the receiver operating characteristics curve of MNA was 0.903 and 0.834, respectively.

CONCLUSIONS

MNA can be a useful tool for frailty screening indicating that 2 common geriatric syndromes, malnutrition and frailty, can be identified by MNA simultaneously in clinical practice.