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Schroeder SE. Frailty and Ventricular Assist Devices: Implications for Advanced Practice Registered Nurses. AACN Adv Crit Care 2024; 35:168-172. [PMID: 38848566 DOI: 10.4037/aacnacc2024909] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/09/2024]
Affiliation(s)
- Sarah E Schroeder
- Sarah E. Schroeder is Nurse Practitioner and Ventricular Assist Device Program Manager, Division of Mechanical Circulatory Support, Bryan Heart, 1600 South 48th Street, Ste 600, Lincoln, NE 68506
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2
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Niebauer J, Bäck C, Bischoff-Ferrari HA, Dehbi HM, Szekely A, Völler H, Sündermann SH. Preinterventional frailty assessment in patients scheduled for cardiac surgery or transcatheter aortic valve implantation: a consensus statement of the European Association for Cardio-Thoracic Surgery (EACTS) and the European Association of Preventive Cardiology (EAPC) of the European Society of Cardiology (ESC). Eur J Prev Cardiol 2024; 31:146-181. [PMID: 37804173 DOI: 10.1093/eurjpc/zwad304] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/10/2022] [Revised: 03/22/2023] [Indexed: 10/09/2023]
Affiliation(s)
- Josef Niebauer
- Paracelsus Medical University Salzburg, Institute of Sports Medicine, Prevention and Rehabilitation, Salzburg, Austria
- Ludwig Boltzmann Institute for Digital Health and Prevention, Salzburg, Austria
- REHA-Zentrum Salzburg, University Hospital Salzburg, Austria
| | - Caroline Bäck
- Department of Cardiothoracic Surgery, RT, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark
| | - Heike A Bischoff-Ferrari
- Center on Ageing and Mobility, University Hospital and University of Zurich, Zurich, Switzerland
| | - Hakim-Moulay Dehbi
- University College London, Comprehensive Clinical Trials Unit, London, Great Britain
| | - Andrea Szekely
- Semmelweis University, Department of Anesthesiology and Intensive Therapy, Budapest, Hungary
| | - Heinz Völler
- Faculty of Health Sciences Brandenburg, University of Potsdam, Department of Rehabilitation Medicine, Potsdam, Germany
- Klinik am See, Rehabilitation Centre for Internal Medicine, Rüdersdorf, Germany
| | - Simon H Sündermann
- Deutsches Herzzentrum der Charité, Department of Cardiothoracic and Vascular Surgery, Berlin, Germany
- Charité- Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt Universität zu Berlin, Berlin, Germany
- DZHK (German Center of Cardiovascular Research), Partner Site Berlin, Berlin, Germany
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3
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Jawaid O, Salerno C, Ravichandran A. Left Ventricular Assist Device and the Current State of the Art: HeartMate 3 at 5 Years. Heart Fail Clin 2024; 20:83-89. [PMID: 37953024 DOI: 10.1016/j.hfc.2023.05.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2023]
Abstract
Left ventricular assist devices (LVADs) or cardiac transplantation are the two prevailing methods of treating patients with end-stage heart failure. The availability of donor hearts is insufficient to meet the needs of patients with advanced heart failure. LVADs offer a potential alternative to transplantation for those patients who cannot wait or are otherwise unsuited for cardiac transplantation. The field has made tremendous progress in the past 20 years. In this review, the current state of the art is summarized with respect to current generation LVADs.
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Affiliation(s)
- Omar Jawaid
- St. Vincents' Ascension, 8333 Naab Road, Indianapolis, IN 46260, USA
| | - Christopher Salerno
- University of Chicago Medical Center, 5841 South Maryland Avenue, Chicago, IL 60637, USA
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Imburgio S, Udongwo N, Mararenko A, Johal A, Tafa M, Akhlaq H, Dandu S, Hossain M, Alshami A, Sealove B, Almendral J, Heaton J. Impact of Frailty on Left Ventricular Assist Device Clinical Outcomes. Am J Cardiol 2023; 207:69-74. [PMID: 37734302 DOI: 10.1016/j.amjcard.2023.08.171] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/13/2023] [Revised: 08/26/2023] [Accepted: 08/26/2023] [Indexed: 09/23/2023]
Abstract
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.
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Affiliation(s)
- Steven Imburgio
- Department of Medicine, Jersey Shore University Medical Center, Neptune City, New Jersey.
| | - Ndausung Udongwo
- Department of Cardiology, Jersey Shore University Medical Center, Neptune City, New Jersey
| | - Anton Mararenko
- Department of Cardiology, Jersey Shore University Medical Center, Neptune City, New Jersey
| | - Anmol Johal
- Department of Medicine, Jersey Shore University Medical Center, Neptune City, New Jersey
| | - Medin Tafa
- Department of Medicine, Jersey Shore University Medical Center, Neptune City, New Jersey
| | - Hira Akhlaq
- Department of Medicine, Jersey Shore University Medical Center, Neptune City, New Jersey
| | - Sowmya Dandu
- Department of Medicine, Jersey Shore University Medical Center, Neptune City, New Jersey
| | - Mohammad Hossain
- Department of Medicine, Jersey Shore University Medical Center, Neptune City, New Jersey
| | - Abbas Alshami
- Department of Cardiology, Jersey Shore University Medical Center, Neptune City, New Jersey
| | - Brett Sealove
- Department of Cardiology, Jersey Shore University Medical Center, Neptune City, New Jersey
| | - Jesus Almendral
- Department of Cardiology, Jersey Shore University Medical Center, Neptune City, New Jersey
| | - Joseph Heaton
- Department of Medicine, Jersey Shore University Medical Center, Neptune City, New Jersey
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5
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Sündermann SH, Bäck C, Bischoff-Ferrari HA, Dehbi HM, Szekely A, Völler H, Niebauer J. Preinterventional frailty assessment in patients scheduled for cardiac surgery or transcatheter aortic valve implantation: a consensus statement of the European Association for Cardio-Thoracic Surgery (EACTS) and the European Association of Preventive Cardiology (EAPC) of the European Society of Cardiology (ESC). Eur J Cardiothorac Surg 2023; 64:ezad181. [PMID: 37804175 DOI: 10.1093/ejcts/ezad181] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/10/2022] [Revised: 03/22/2023] [Indexed: 10/09/2023] Open
Affiliation(s)
- Simon H Sündermann
- Deutsches Herzzentrum der Charité, Department of Cardiothoracic and Vascular Surgery, Berlin, Germany
- Charité- Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt Universität zu Berlin, Berlin, Germany
- DZHK (German Center of Cardiovascular Research), Partner Site Berlin, Berlin, Germany
| | - Caroline Bäck
- Department of Cardiothoracic Surgery, RT, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark
| | - Heike A Bischoff-Ferrari
- Center on Ageing and Mobility, University Hospital and University of Zurich, Zurich, Switzerland
| | - Hakim-Moulay Dehbi
- University College London, Comprehensive Clinical Trials Unit, London, Great Britain
| | - Andrea Szekely
- Semmelweis University, Department of Anesthesiology and Intensive Therapy, Budapest, Hungary
| | - Heinz Völler
- Faculty of Health Sciences Brandenburg, University of Potsdam, Department of Rehabilitation Medicine, Potsdam, Germany
- Klinik am See, Rehabilitation Centre for Internal Medicine, Rüdersdorf, Germany
| | - Josef Niebauer
- Paracelsus Medical University Salzburg, Institute of Sports Medicine, Prevention and Rehabilitation, Salzburg, Austria
- Ludwig Boltzmann Institute for Digital Health and Prevention, Salzburg, Austria
- REHA-Zentrum Salzburg, University Hospital Salzburg, Austria
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6
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Talha KM, Pandey A, Fudim M, Butler J, Anker SD, Khan MS. Frailty and heart failure: State-of-the-art review. J Cachexia Sarcopenia Muscle 2023; 14:1959-1972. [PMID: 37586848 PMCID: PMC10570089 DOI: 10.1002/jcsm.13306] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/29/2022] [Revised: 06/16/2023] [Accepted: 07/11/2023] [Indexed: 08/18/2023] Open
Abstract
At least half of all patients with heart failure (HF) are affected by frailty, a syndrome that limits an individual ability to recover from acute stressors. While frailty affects up to 90% of patients with HF with preserved ejection fraction, it is also seen in ~30-60% of patients with HF with reduced ejection fraction, with ~26% higher prevalence in women compared with men. The relationship between frailty and HF is bidirectional, with both conditions exacerbating the other. Frailty is further complicated by a higher prevalence of sarcopenia (by ~20%) in HF patients compared with patients without HF, which negatively affects outcomes. Several frailty assessment methods have been employed historically including the Fried frailty phenotype and Rockwood Clinical Frailty Scale to classify HF patients based on the severity of frailty; however, a validated HF-specific frailty assessment tool does not currently exist. Frailty in HF is associated with a poor prognosis with a 1.5-fold to 2-fold higher risk of all-cause death and hospitalizations compared to non-frail patients. Frailty is also highly prevalent in patients with worsening HF, affecting >50% of patients hospitalized for HF. Such patients with multiple readmissions for decompensated HF have markedly poor outcomes compared to younger, non-frail cohorts, and it is hypothesized that it may be due to major physical and functional limitations that limit recovery from an acute episode of worsening HF, a care aspect that has not been addressed in HF guidelines. Frail patients are thought to confer less benefit from therapeutic interventions due to an increased risk of perceived harm, resulting in lower adherence to HF interventions, which may worsen outcomes. Multiple studies report that <40% of frail patients are on guideline-directed medical therapy for HF, of which most are on suboptimal doses of these medications. There is a lack of evidence generated from randomized trials in this incredibly vulnerable population, and most current practice is governed by post hoc analyses of trials, observational registry-based data and providers' clinical judgement. The current body of evidence suggests that the treatment effect of most guideline-based interventions, including medications, cardiac rehabilitation and device therapy, is consistent across all age groups and frailty subgroups and, in some cases, may be amplified in the older, more frail population. In this review, we discuss the characteristics, assessment tools, impact on prognosis and impact on therapeutic interventions of frailty in patients with HF.
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Affiliation(s)
- Khawaja M. Talha
- Department of MedicineUniversity of Mississippi Medical CenterJacksonMSUSA
| | - Ambarish Pandey
- Division of CardiologyUniversity of Texas Southwestern Medical CenterDallasTXUSA
| | - Marat Fudim
- Division of CardiologyDuke University Hospital, Duke University School of MedicineDurhamNCUSA
- Duke Clinical Research InstituteDurhamNCUSA
| | - Javed Butler
- Department of MedicineUniversity of Mississippi Medical CenterJacksonMSUSA
- Baylor Scott and White Research InstituteDallasTXUSA
| | - Stefan D. Anker
- Department of Cardiology (CVK) of German Heart Center CharitéInstitute of Health Center for Regenerative Therapies (BCRT), German Centre for Cardiovascular Research (DZHK) partner site Berlin, Charité UniversitätsmedizinBerlinGermany
- Institute of Heart DiseasesWroclaw Medical UniversityWroclawPoland
| | - Muhammad Shahzeb Khan
- Division of CardiologyDuke University Hospital, Duke University School of MedicineDurhamNCUSA
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Nayak A, Hall SA, Uriel N, Goldstein DJ, Cleveland JC, Cowger JA, Salerno CT, Naka Y, Horstmanshof D, Crandall D, Wang A, Mehra MR. Predictors of 5-Year Mortality in Patients Managed With a Magnetically Levitated Left Ventricular Assist Device. J Am Coll Cardiol 2023; 82:771-781. [PMID: 37612008 DOI: 10.1016/j.jacc.2023.05.066] [Citation(s) in RCA: 8] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/11/2023] [Accepted: 05/31/2023] [Indexed: 08/25/2023]
Abstract
BACKGROUND In advanced heart failure patients implanted with a fully magnetically levitated HeartMate 3 (HM3, Abbott) left ventricular assist device (LVAD), it is unknown how preimplant factors and postimplant index hospitalization events influence 5-year mortality in those able to be discharged. OBJECTIVES The goal was to identify risk predictors of mortality through 5 years among HM3 LVAD recipients conditional on discharge from index hospitalization in the MOMENTUM 3 pivotal trial. METHODS This analysis evaluated 485 of 515 (94%) patients discharged after implantation of the HM3 LVAD. Preimplant (baseline), implant surgery, and index hospitalization characteristics were analyzed individually, and as multivariable predictors for mortality risk through 5 years. RESULTS Cumulative 5-year mortality in the cohort (median age: 62 years, 80% male, 65% White, 61% destination therapy due to transplant ineligibility) was 38%. Two preimplant characteristics (elevated blood urea nitrogen and prior coronary artery bypass graft or valve procedure) and 3 postimplant characteristics (hemocompatibility-related adverse events, ventricular arrhythmias, and estimated glomerular filtration rate <60 mL/min/1.73 m2 at discharge) were predictors of 5-year mortality. In 171 of 485 patients (35.3%) without any risk predictors, 5-year mortality was reduced to 22.6% (95% CI: 15.4%-32.7%). Even among those with 1 or more predictors, mortality was <50% at 5 years (45.7% [95% CI: 39.0%-52.8%]). CONCLUSIONS Long-term survival in successfully discharged HM3 LVAD recipients is largely influenced by clinical events experienced during the index surgical hospitalization in tandem with baseline factors, with mortality of <50% at 5 years. In patients without identified predictors of risk, long-term 5-year mortality is low and rivals that achieved with heart transplantation, even though most were implanted with destination therapy intent. (MOMENTUM 3 IDE Clinical Study Protocol, NCT02224755; MOMENTUM 3 Pivotal Cohort Extended Follow-up PAS, NCT03982979).
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Affiliation(s)
- Aditi Nayak
- Brigham and Women's Hospital and Harvard Medical School, Boston, Massachusetts, USA
| | | | - Nir Uriel
- Columbia University College of Physicians and Surgeons and New York-Presbyterian Hospital, New York, New York, USA
| | - Daniel J Goldstein
- Montefiore Einstein Center for Heart and Vascular Care, New York, New York, USA
| | | | | | | | | | | | | | | | - Mandeep R Mehra
- Brigham and Women's Hospital and Harvard Medical School, Boston, Massachusetts, USA.
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Hsi B, Province V, Tang WHW. Frailty in the Advanced Heart Failure Patient: A Challenging, Neglected, Yet Potentially Modifiable Risk Factor. CURRENT TREATMENT OPTIONS IN CARDIOVASCULAR MEDICINE 2023; 25:261-271. [PMID: 38292930 PMCID: PMC10824513 DOI: 10.1007/s11936-023-00992-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 05/10/2023] [Indexed: 02/01/2024]
Abstract
Purpose of review There is an increasing push for frailty assessment to become a routine part of the evaluation of potential candidates for advanced heart failure (AHF) therapies. The aim of this review is to highlight the importance of frailty in the care of the AHF patient. Recent findings This review focuses on some of the available data for the assessment of frailty specifically in the AHF, durable mechanical circulatory support (MCS), and heart transplant (HT) patients, and explores some of the challenges in assessing frailty in these patient populations. Summary As the presence of frailty can significantly impact outcomes after HT and durable MCS implantation, there should be an increased recognition of this entity during routine evaluation and management of the AHF patient.
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Affiliation(s)
- Brian Hsi
- Center for Advanced Heart and Lung Disease, Baylor University Medical Center, 3410 Worth Street, Suite 250, Dallas, TX 75246, USA
| | - Valesha Province
- Department of Cardiovascular and Metabolic Sciences, Lerner Research Institute, Cleveland Clinic, 9500 Euclid Avenue, Desk J3-4,, Cleveland, OH 44195, USA
| | - W. H. Wilson Tang
- Department of Cardiovascular and Metabolic Sciences, Lerner Research Institute, Cleveland Clinic, 9500 Euclid Avenue, Desk J3-4,, Cleveland, OH 44195, USA
- Department of Cardiovascular Medicine, Heart Vascular and Thoracic Institute, Cleveland Clinic, 9500 Euclid Avenue, Desk J3-4,, Cleveland, OH 44195, USA
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Sokos G, Kido K, Panjrath G, Benton E, Page R, Patel J, Smith PJ, Korous S, Guglin M. Multidisciplinary Care in Heart Failure Services. J Card Fail 2023; 29:943-958. [PMID: 36921886 DOI: 10.1016/j.cardfail.2023.02.011] [Citation(s) in RCA: 7] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2022] [Revised: 02/01/2023] [Accepted: 02/05/2023] [Indexed: 03/18/2023]
Abstract
The American College of Cardiology/American Heart Association/Heart Failure Society of American 2022 guidelines for heart failure (HF) recommend a multidisciplinary team approach for patients with HF. The multidisciplinary HF team-based approach decreases the hospitalization rate for HF and health care costs and improves adherence to self-care and the use of guideline-directed medical therapy. This article proposes the optimal multidisciplinary team structure and each team member's delineated role to achieve institutional goals and metrics for HF care. The proposed HF-specific multidisciplinary team comprises cardiologists, surgeons, advanced practice providers, clinical pharmacists, specialty nurses, dieticians, physical therapists, psychologists, social workers, immunologists, and palliative care clinicians. A standardized multidisciplinary HF team-based approach should be incorporated to optimize the structure, minimize the redundancy of clinical responsibilities among team members, and improve clinical outcomes and patient satisfaction in their HF care.
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Affiliation(s)
- George Sokos
- Department of Cardiology, West Virginia University School of Medicine, Morgantown, West Virginia
| | - Kazuhiko Kido
- Department of Clinical Pharmacy, West Virginia University School of Pharmacy, Morgantown, West Virginia.
| | - Gurusher Panjrath
- School of Medicine and Health Sciences, George Washington University, North Englewood, Maryland
| | - Emily Benton
- Department of Medicine, University of Colorado, Boulder, Colorado
| | - Robert Page
- Department of Clinical Pharmacy, at the University of Colorado Denver Skaggs School of Pharmacy, Denver, Colorado
| | - Jignesh Patel
- Department of Medicine, Cedars-Sinai Medical Center, Los Angeles, California
| | - Patrick J Smith
- Psychiatry, University of North Carolina School of Medicine, Chapel Hill, North Carolina
| | - Shelly Korous
- Advanced Heart Failure Program, Indiana University Health, Indianapolis, Indiana
| | - Maya Guglin
- Department of Medicine, Indiana University Health, Indianapolis, Indiana
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10
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Shetty NS, Parcha V, Abdelmessih P, Patel N, Hasnie AA, Kalra R, Pandey A, Breathett K, Morris AA, Arora G, Arora P. Sex-Associated Differences in the Clinical Outcomes of Left Ventricular Assist Device Recipients: Insights From Interagency Registry for Mechanically Assisted Circulatory Support. Circ Heart Fail 2023; 16:e010189. [PMID: 37232167 PMCID: PMC10421565 DOI: 10.1161/circheartfailure.122.010189] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/16/2022] [Accepted: 02/20/2023] [Indexed: 05/27/2023]
Abstract
BACKGROUND Sex-associated differences in clinical outcomes among left ventricular assist device recipients in the United States have been recognized. However, an investigation of the social and clinical determinants of sex-associated differences is lacking. METHODS Left ventricular assist device receiving patients enrolled in Interagency Registry for Mechanically Assisted Circulatory Support between 2005 and 2017 were included. The primary outcome was all-cause mortality. Secondary outcomes included heart transplantation and postimplantation adverse event rates. The cohort was stratified by the social subgroup of race and ethnicity (non-Hispanic White, non-Hispanic Black, non-Hispanic Asian, and Hispanic), and clinical subgroups of device strategy (destination therapy, bridge to transplant, and bridge to candidacy), and implantation center volume (low [≤20 implants/y], medium [21-30 implants/y], and high [>30 implants/y]). A multivariable-adjusted Cox proportional hazard model was used to assess the risk of death and heart transplantation with prespecified interaction testing. Poisson regression was used to estimate adverse events by sex across the various subgroups. RESULTS Among 18 525 patients, there were 3968 (21.4%) females. Compared with their male counterparts, Hispanic (adjusted hazard ratio [HRadj], 1.75 [1.23-2.47]) females had the highest risk of death followed by non-Hispanic White females (HRadj, 1.15 [1.07-1.25]; Pinteraction=0.02). Hispanic (HRadj, 0.60 [0.40-0.89]) females had the lowest cumulative incidence of heart transplantation followed by non-Hispanic Black females (HRadj, 0.76 [0.67-0.86]), and non-Hispanic White females (HRadj, 0.88 [0.80-0.96]) compared with their male counterparts (Pinteraction<0.001). Compared with their male counterparts, females on the bridge to candidacy strategy (HRadj, 1.32 [1.18-1.48]) had the highest risk of death (Pinteraction=0.01). The risk of death (Pinteraction=0.44) and cumulative incidence of heart transplantation (Pinteraction=0.40) did not vary by sex in the center volume subgroup. A higher incidence rate of adverse events after left ventricular assist device implantation was also seen in females compared with the males, overall, and across all subgroups. CONCLUSIONS Among left ventricular assist device recipients, the risk of death, the cumulative incidence of heart transplantation, and adverse events differ by sex across the social and clinical subgroups.
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Affiliation(s)
- Naman S. Shetty
- Division of Cardiovascular Disease, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Vibhu Parcha
- Division of Cardiovascular Disease, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Peter Abdelmessih
- Department of Medicine, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Nirav Patel
- Division of Cardiovascular Disease, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Ammar A. Hasnie
- Department of Medicine, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Rajat Kalra
- Cardiovascular Division, University of Minnesota, Minneapolis, MN, USA
| | - Ambarish Pandey
- Division of Cardiology, Department of Internal Medicine, University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - Khadijah Breathett
- Division of Cardiology, Indiana University School of Medicine, Indianapolis, IN, USA
| | - Alanna A. Morris
- Division of Cardiology, Emory University School of Medicine, Atlanta, GA, USA
| | - Garima Arora
- Division of Cardiovascular Disease, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Pankaj Arora
- Division of Cardiovascular Disease, University of Alabama at Birmingham, Birmingham, AL, USA
- Section of Cardiology, Birmingham Veterans Affairs Medical Center, Birmingham, AL, USA
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Heaney C, Knisel A, Vuthoori R, Golombeck D, Fernandez H, Lima B, Taylor J, Davidson K, Kennedy K, Nursey V, Miller E, Maybaum S. Subjective Assessment Underestimates Fraility in Patients With Heart Failure Referred for Advanced Therapies. ASAIO J 2023; 69:588-594. [PMID: 36804288 DOI: 10.1097/mat.0000000000001894] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/22/2023] Open
Abstract
Assessment of frailty is key for evaluation for advanced therapies (ATs). Most programs use a subjective provider assessment (SPA) or "eye-ball" test; however, objective measures exist. The modified five-item Fried Frailty Index (mFFI) is a validated tool to assess frailty. We compared SPA to mFFI testing in patients referred for AT. We also compared levels of macrophage migration inhibitory factor (MIF), an inflammatory biomarker associated with worse outcomes in heart failure, between frail and not frail subjects. Seventy-eight patients referred for evaluation for AT underwent both SPA and mFFI testing. Three cardiac surgeons independently assessed patients for frailty (SPA). SPA significantly underestimated frailty compared with mFFI testing and correlation between SPA and mFFI was not strong (κ = 0.02-0.14). Providers were correct 84% of the time designating a subject as frail, but only 40% of the time designating as not frail. Agreement between all three providers was robust (76%), which was primarily driven by designation as not frail. There was no significant difference in plasma MIF levels between frail and not frail subjects (47.6 ± 25.2 vs . 45.2 ± 18.9 ng/ml; p = 0.6). Clinicians significantly underestimate frailty but are usually correct when designating a patient as frail.
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Affiliation(s)
- Cassandra Heaney
- From the Donald and Barbara Zucker School of Medicine at Hofstra/Northwell is in Manhasset, New York, USA
| | - Alexis Knisel
- From the Donald and Barbara Zucker School of Medicine at Hofstra/Northwell is in Manhasset, New York, USA
| | - Ravi Vuthoori
- Department of Cardiovascular and Thoracic Surgery, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell is in Manhasset, New York, USA
| | - David Golombeck
- Department of Cardiovascular and Thoracic Surgery, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell is in Manhasset, New York, USA
| | - Harold Fernandez
- Department of Cardiovascular and Thoracic Surgery, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell is in Manhasset, New York, USA
| | - Brian Lima
- Department of Cardiovascular and Thoracic Surgery, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell is in Manhasset, New York, USA
| | - James Taylor
- Department of Cardiovascular and Thoracic Surgery, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell is in Manhasset, New York, USA
| | - Kathleen Davidson
- Department of Cardiovascular and Thoracic Surgery, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell is in Manhasset, New York, USA
| | - Kevin Kennedy
- Statistical Consultant for Northwell Health is in Kansas City, Missouri, USA
| | - Vishaan Nursey
- From the Donald and Barbara Zucker School of Medicine at Hofstra/Northwell is in Manhasset, New York, USA
| | - Ed Miller
- RDS2 Solutions Research Division is in Stony Brook, New York, USA
| | - Simon Maybaum
- From the Donald and Barbara Zucker School of Medicine at Hofstra/Northwell is in Manhasset, New York, USA
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Meece LE, Yu J, Winchester DE, Petersen M, Jeng EI, Al-Ani MA, Parker AM, Vilaro JR, Aranda JM, Ahmed MM. Prognostic Value of Frailty for Heart Failure Patients Undergoing Left Ventricular Assist Device Implantation: A Systematic Review. Cardiol Rev 2023; Publish Ahead of Print:00045415-990000000-00081. [PMID: 36881614 DOI: 10.1097/crd.0000000000000541] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 03/08/2023]
Abstract
Frailty is associated with poor clinical outcomes in heart failure patients. The impact of frailty on outcomes following left ventricular assist device (LVAD) implantation, however, is less clearly defined. We therefore sought to conduct a systematic review to evaluate current frailty assessment strategies and their significance for patients undergoing LVAD implantation. We conducted a comprehensive electronic search of PubMed, Embase, and CINAHL databases from inception until April 2021 for studies examining frailty in patients undergoing LVAD implantation. Study characteristics, patient demographics, type of frailty measurement, and outcomes were extracted. Outcomes were organized into 5 basic categories: implant length of stay (iLOS), 1-year mortality, rehospitalization, adverse events, and quality of life (QOL). Of the 260 records retrieved, 23 studies involving 4935 patients satisfied the inclusion criteria. Approaches to measuring frailty varied, with the 2 most common being sarcopenia determined by computed tomography and Fried's frailty phenotype assessment. Outcomes of interest were also widely variable, with iLOS stay and mortality being the most frequently reported, albeit with differing definitions of both between studies. The heterogeneity among included studies precluded quantitative synthesis. Narrative synthesis showed that frailty by any measure is more likely to be associated with higher mortality, longer iLOS, more adverse events and worse QOL post-LVAD implant. Frailty can be a valuable prognostic indicator in patients undergoing LVAD implantation. Further studies are needed to determine the most sensitive frailty assessment, as well as the ways in which frailty may serve as a modifiable target to improve outcomes following LVAD implantation.
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Affiliation(s)
- Lauren E Meece
- From the Division of Cardiovascular Medicine, University of Florida, Gainesville, FL
| | - Julia Yu
- Sidney Kimmel Medical College at Thomas Jefferson University, Philadelphia, PA
| | - David E Winchester
- From the Division of Cardiovascular Medicine, University of Florida, Gainesville, FL
| | | | - Eric I Jeng
- Division of Thoracic and Cardiovascular Surgery, University of Florida, Gainesville, FL
| | - Mohammad A Al-Ani
- From the Division of Cardiovascular Medicine, University of Florida, Gainesville, FL
| | - Alex M Parker
- From the Division of Cardiovascular Medicine, University of Florida, Gainesville, FL
| | - Juan R Vilaro
- From the Division of Cardiovascular Medicine, University of Florida, Gainesville, FL
| | - Juan M Aranda
- From the Division of Cardiovascular Medicine, University of Florida, Gainesville, FL
| | - Mustafa M Ahmed
- From the Division of Cardiovascular Medicine, University of Florida, Gainesville, FL
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13
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Ajibawo T, Chauhan P, Gopalan R. Impact of Fried Frailty Phenotype on Postoperative Outcomes After Durable Contemporary Mechanical Circulatory Support: A Single-Center Experience. Cardiol Res 2022; 13:315-322. [PMID: 36660060 PMCID: PMC9822670 DOI: 10.14740/cr1423] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/22/2022] [Accepted: 10/08/2022] [Indexed: 12/23/2022] Open
Abstract
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.
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Affiliation(s)
- Temitope Ajibawo
- Department of Medicine, Banner University Medical Center, Phoenix, AZ 85006, USA,Corresponding Author: Temitope Ajibawo, Department of Medicine, Banner University Medical Center, Phoenix, AZ 85006, USA.
| | - Priyank Chauhan
- Department of Medicine, Banner University Medical Center, Phoenix, AZ 85006, USA
| | - Radha Gopalan
- Division of Cardiology, Department of Medicine, Banner University Medical Center, Phoenix, AZ 85006, USA
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Erdoğan SB, Barutça H, Bastopcu M, Sargın M, Albeyoğlu Ş. Is pectoralis muscle index a risk factor for mortality in left ventricular assist device patients? Rev Assoc Med Bras (1992) 2022; 68:1692-1697. [PMID: 36449796 PMCID: PMC9779975 DOI: 10.1590/1806-9282.20220744] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2022] [Accepted: 08/17/2022] [Indexed: 12/23/2022] Open
Abstract
OBJECTIVE We aimed to investigate whether sarcopenia measured from pectoralis muscles is a risk factor for long-term mortality in left ventricular assist device patients. METHODS Patients aged >18 years implanted with a left ventricular assist device in a single center between 2013 and 2019 were retrospectively included. Patients without a thoracic computed tomography scan performed within 3 months of left ventricular assist device implantation and without computed tomography scans appropriate for pectoralis muscle measurement were excluded. Pectoralis muscle measurements were made on thoracic computed tomography slices, and pectoralis muscle indices were calculated for each patient. Sarcopenia was defined as being in the gender-specific lowest tertile of pectoralis muscle index. Survival was compared between patients with and without sarcopenia. RESULTS The study was conducted on 64 left ventricular assist device patients who met the inclusion criteria. Notably, 21 (32.8%) of the study patients were sarcopenic. Diabetes mellitus and sarcopenia were more common in patients with 2-year mortality in our cohort. Patients with sarcopenia had a worse 2-year survival (p<0.001). Sarcopenia had an adjusted hazard ratio of 4.04 (95% confidence interval (CI) 1.36-12.02, p=0.012), while diabetes mellitus was associated with an adjusted hazard ratio of 3.14 (95%CI 1.17-8.39, p=0.023). CONCLUSION Sarcopenia defined by low pectoralis muscle index increases the risk for 2-year mortality in left ventricular assist device patients.
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Affiliation(s)
- Sevinç Bayer Erdoğan
- Dr. Siyami Ersek Thoracic and Cardiovascular Surgery Training and Research Hospital, Department of Cardiovascular Surgery – Istanbul, Turkey.,Corresponding author:
| | - Hakan Barutça
- Dr. Siyami Ersek Thoracic and Cardiovascular Surgery Training and Research Hospital, Department of Radiology – Istanbul, Turkey
| | - Murat Bastopcu
- Dr. Siyami Ersek Thoracic and Cardiovascular Surgery Training and Research Hospital, Department of Cardiovascular Surgery – Istanbul, Turkey
| | - Murat Sargın
- Dr. Siyami Ersek Thoracic and Cardiovascular Surgery Training and Research Hospital, Department of Cardiovascular Surgery – Istanbul, Turkey
| | - Şebnem Albeyoğlu
- Dr. Siyami Ersek Thoracic and Cardiovascular Surgery Training and Research Hospital, Department of Cardiovascular Surgery – Istanbul, Turkey
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15
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Ajibawo T, Chauhan P, Gopalan RS, Agarwal NK. The prognostic value of clinical frailty scale and outcomes in older patients undergoing left ventricular assist device implantation. Aging Med (Milton) 2022; 5:257-263. [PMID: 36606267 PMCID: PMC9805295 DOI: 10.1002/agm2.12227] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2022] [Revised: 10/15/2022] [Accepted: 10/16/2022] [Indexed: 11/19/2022] Open
Abstract
Objectives Heart failure impacts patients' functional capabilities, ultimately leading to frailty. The use of a left ventricular assist device (LVAD) is acceptable as both destination therapy and bridge to transplant in heart failure management. We aim to evaluate the prognostic value of the Clinical Frailty Scale (CFS) on outcomes in older patients undergoing implantation of LVAD. Methods We conducted a retrospective chart review of patients ≥ 60 years old that underwent LVAD implantation at our medical center from May 1, 2018, to October 30, 2020. CFS was retrospectively assigned before LVAD placement and CFS scores > 4 was considered frail. Kaplan-Meier curves and Cox regression were used to analyze 1-year survival estimates. Results Forty percent of the cohort was classified as frail according to CFS. Thirty-day re-admission rates were comparable between frail and non-frail patients (46% vs 35%; P = 0.419). 1-year survival was lower in the frail vs non-frail group (log rank, P = 0.017). On Cox analysis, only frailty was associated with 1-year post-intervention mortality (hazard ratio [HR] = 5.64, 95% confidence interval [CI] = 1.131-28.212; P = 0.035). Conclusions CFS-defined frailty was associated with increased risk of 1-year mortality after LVAD implantation. CFS may be a valuable tool in the frailty assessment for risk stratification of patients undergoing LVAD implantation. Multicenter studies are required to validate these findings.
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Affiliation(s)
- Temitope Ajibawo
- Division of Geriatric Medicine, Department of Internal MedicineBanner University Medical CenterPhoenixArizonaUSA
| | - Priyank Chauhan
- Division of Geriatric Medicine, Department of Internal MedicineBanner University Medical CenterPhoenixArizonaUSA
| | - Radha S. Gopalan
- Division of Cardiology, Department of Internal MedicineBanner University Medical CenterPhoenixArizonaUSA
| | - Nimit K. Agarwal
- Division of Geriatric Medicine, Department of Internal MedicineBanner University Medical CenterPhoenixArizonaUSA
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16
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Subramanian H, Knight J, Sultan I, Kaczorowski DJ, Subramaniam K. Pre-Habilitation of Cardiac Surgical Patients, Part 2: Frailty, Malnutrition, Respiratory disease, Alcohol/Smoking cessation and Depression. Semin Cardiothorac Vasc Anesth 2022; 26:295-303. [PMID: 36189933 DOI: 10.1177/10892532221130922] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
The concept of "pre-habilitation" comprises screening for and identification of pre-existing disorders followed by medical optimization. This is performed for many types of surgeries, but may have profound impacts on outcomes, particularly in cardiac surgery given the multiple comorbidities typically carried by these patients. Components of pre-habilitation include direct medical intervention by preoperative specialists as well as significant care coordination and shared decision-making. In this second part of a two-part review, the authors describe existing evidence to support the optimization of various preoperative problems and present a few institutional protocols utilized at out center for cardiac presurgical care. This second installment will focus on alcohol and smoking cessation and the management of frailty, malnutrition, respiratory disease, and depression.
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Affiliation(s)
- Harikesh Subramanian
- Department of Anesthesiology and Perioperative Medicine, 6595University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - Joshua Knight
- Department of Anesthesiology and Perioperative Medicine, 6595University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - Ibrahim Sultan
- Department of Cardiothoracic Surgery, 481457University of Pittsburgh Medical center, Pittsburgh, PA, USA
| | - David J Kaczorowski
- Department of Cardiothoracic Surgery, 481457University of Pittsburgh Medical center, Pittsburgh, PA, USA
| | - Kathirvel Subramaniam
- Department of Anesthesiology and Perioperative Medicine, 6595University of Pittsburgh Medical Center, Pittsburgh, PA, USA
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17
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Leininger S, Davis Micco RN. The Future of Assessing Frailty in the Patient With Advanced Heart Failure: A Review of Current Literature. Crit Care Nurs Q 2022; 45:359-375. [PMID: 35980798 DOI: 10.1097/cnq.0000000000000428] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Frailty is becoming an important component of health care outcomes in patients with a diagnosis of heart failure. A literature search was completed to determine whether a best practice guideline existed to assess frailty in patients who were considering ventricular assist device placement. The literature search revealed that best practice guidelines did not exist. A second comprehensive literature search was completed specifically for frailty including the definition, criteria, assessment, and outcomes. The studies revealed that there were challenges with defining frailty, the age of frailty, assessments tools, and study designs. Cardiologists are primarily interested in screening for frailty, but other physician specialty practices are interested in a frailty screening tool as well. This article discusses the inconsistent research studies and the need for a valid and reliable tool to assess for frailty. It is important that nurse leaders and those working with heart failure patients determine the best practice guidelines for assessing frailty.
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18
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Vidula H, Takeda K, Estep JD, Silvestry SC, Milano C, Cleveland JC, Goldstein DJ, Uriel N, Kormos RL, Dirckx N, Mehra MR. Hospitalization Patterns and Impact of a Magnetically-Levitated Left Ventricular Assist Device in the MOMENTUM 3 Trial. JACC. HEART FAILURE 2022; 10:470-481. [PMID: 35772857 DOI: 10.1016/j.jchf.2022.03.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/28/2022] [Revised: 03/22/2022] [Accepted: 03/31/2022] [Indexed: 10/18/2022]
Abstract
BACKGROUND In the MOMENTUM 3 (Multicenter Study of MagLev Technology in Patients Undergoing Mechanical Circulatory Support Therapy with HeartMate 3) pivotal trial, the HeartMate 3 (HM3) fully magnetically levitated left ventricular assist device (LVAD) demonstrated superiority over the axial-flow HeartMate II (HMII) LVAD. The patterns and predictors of hospitalizations with the HM3 LVAD have not been characterized. OBJECTIVES This study sought to determine causes, predictors, and impact of hospitalizations during LVAD support. METHODS Patients discharged after LVAD implantation were analyzed. In the pivotal trial, 485 recipients of HM3 were compared with 471 recipients of HMII. The pivotal trial HM3 group was also compared to 949 recipients of HM3 in the postapproval phase within the trial portfolio. Predictors of cause-specific rehospitalization were analyzed. RESULTS The rates of rehospitalization were lower with HM3 LVAD than with HMII LVAD in the pivotal trial (225.7 vs 246.4 events per 100 patient-years; P < 0.05). Overall, rehospitalization rates and duration were similar in the HM3 postapproval phase and pivotal trial but prolonged hospitalizations (>7 days) were less frequent (rate ratio: 0.90 [95% CI: 0.80-0.98]; P < 0.05). In HM3 recipients, the most frequent causes of rehospitalization included infection, heart failure (HF)-related events, and bleeding. First rehospitalization caused by HF-related event versus other causes was associated with reduced survival (HR: 2.2 [95% CI: 1.3-3.9]; P = 0.0014). Male sex, non-White race, presence of cardiac resynchronization therapy/implantable cardioverter-defibrillator, obesity, higher right atrial pressure, smaller LV size, longer duration of index hospitalization, and lower estimated glomerular filtration rate at index discharge predicted HF hospitalizations. CONCLUSIONS Contemporary support with the HM3 fully magnetically levitated LVAD is associated with a lower hospitalization burden than with prior pumps; however, rehospitalizations for infection, HF, and bleeding remain important challenges for progress in the patient journey. (MOMENTUM 3 IDE Clinical Study, NCT02224755; MOMENTUM 3 Continued Access Protocol [MOMENTUM 3 CAP], NCT02892955).
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Affiliation(s)
- Himabindu Vidula
- Division of Cardiology, University of Rochester School of Medicine and Dentistry, Rochester, New York, USA
| | - Koji Takeda
- Division of Cardiac, Thoracic, and Vascular Surgery, Columbia University College of Physicians and Surgeons and New York-Presbyterian Hospital, New York, New York, USA
| | - Jerry D Estep
- Kaufman Center for Heart Failure and Recovery, The Cleveland Clinic Foundation, Cleveland, Ohio, USA
| | - Scott C Silvestry
- Thoracic Transplant, Thoracic, and Cardiovascular Surgery Program, AdventHealth Transplant Institute, Orlando, Florida, USA
| | - Carmelo Milano
- Division of Cardiothoracic Surgery, Duke University Medical Center, Durham, North Carolina, USA
| | - Joseph C Cleveland
- Division of Cardiothoracic Surgery, University of Colorado School of Medicine, Aurora, Colorado, USA
| | - Daniel J Goldstein
- Department of Cardiothoracic Surgery, Montefiore Einstein Center for Heart and Vascular Care, New York, New York, USA
| | - Nir Uriel
- Division of Cardiology, Columbia University College of Physicians and Surgeons and New York-Presbyterian Hospital, New York, New York, USA
| | | | | | - Mandeep R Mehra
- Center for Advanced Heart Disease, Brigham and Women's Hospital Heart and Vascular Center and Harvard Medical School, Boston, Massachusetts, USA.
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19
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Krivoshapova KE, Vegner EA, Barbarash OL. [Frailty syndrome as an independent predictor of adverse prognosis in patients with chronic heart failure]. KARDIOLOGIIA 2022; 62:89-96. [PMID: 35414366 DOI: 10.18087/cardio.2022.3.n1206] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/31/2020] [Accepted: 07/29/2020] [Indexed: 06/14/2023]
Abstract
This review presents results of clinical studies of senile asthenia ("fragility") syndrome and chronic heart failure (CHF). Recent reports of the "fragility" prevalence in patients with CHF are described. The review presents specific features of pathophysiological pathways underlying the development of both senile asthenia syndrome and CHF; the role of "fragility" in the progression and complications of CHF is addressed. Senile asthenia syndrome associated with CHF is regarded as an independent predictor of unfavorable prognosis and high mortality in this patient category. The authors concluded that methods for "fragility" evaluation in CHF patients followed by risk stratification and selection of individual management tactics should be implemented in clinical practice.
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Affiliation(s)
- K E Krivoshapova
- Research Institute for Complex Issues of Cardiovascular Diseases
| | | | - Olga L Barbarash
- Research Institute for Complex Issues of Cardiovascular Diseases; Kemerovo State Medical
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20
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Salmon T, Essa H, Tajik B, Isanejad M, Akpan A, Sankaranarayanan R. The Impact of Frailty and Comorbidities on Heart Failure Outcomes. Card Fail Rev 2022; 8:e07. [PMID: 35399550 PMCID: PMC8977991 DOI: 10.15420/cfr.2021.29] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/19/2021] [Accepted: 01/19/2022] [Indexed: 12/16/2022] Open
Abstract
Frailty is a multisystemic process leading to reduction of physiological reserve and a reduction in physical activity. Heart failure (HF) is recognised as a global cause of morbidity and mortality, increasing in prevalence over recent decades. Because of shared phenotypes and comorbidities, there is significant overlap and a bidirectional relationship, with frail patients being at increased risk of developing HF and vice versa. Despite this, frailty is not routinely assessed in patients with HF. Identification of these patients to direct multidisciplinary care is key, and the development of a frailty assessment tool validated in a large HF population is also an unmet need that would be of considerable benefit in directing multidisciplinary-team management. Non-pharmacological treatment should be included, as exercise and physical rehabilitation programmes offer dual benefit in frail HF patients, by treating both conditions simultaneously. The evidence for nutritional supplementation is mixed, but there is evidence that a personalised approach to nutritional support in frail HF patients can improve outcomes.
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Affiliation(s)
- Thomas Salmon
- Department of Cardiology, Aintree University Hospital, Liverpool University Hospitals NHS Foundation Trust, Liverpool UK
| | - Hani Essa
- Department of Cardiology, Aintree University Hospital, Liverpool University Hospitals NHS Foundation Trust, Liverpool UK; Liverpool Centre for Cardiovascular Science, University of Liverpool, Liverpool Heart & Chest Hospital, Liverpool, UK
| | | | - Masoud Isanejad
- Liverpool Centre for Cardiovascular Science, University of Liverpool, Liverpool Heart & Chest Hospital, Liverpool, UK; Institute of Life Course and Medical Sciences, University of Liverpool, Liverpool UK
| | - Asangaedem Akpan
- Department of Cardiology, Aintree University Hospital, Liverpool University Hospitals NHS Foundation Trust, Liverpool UK; Liverpool Centre for Cardiovascular Science, University of Liverpool, Liverpool Heart & Chest Hospital, Liverpool, UK
| | - Rajiv Sankaranarayanan
- Department of Cardiology, Aintree University Hospital, Liverpool University Hospitals NHS Foundation Trust, Liverpool UK; Liverpool Centre for Cardiovascular Science, University of Liverpool, Liverpool Heart & Chest Hospital, Liverpool, UK; National Institute for Health Research, UK
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21
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Wleklik M, Denfeld Q, Lisiak M, Czapla M, Kałużna-Oleksy M, Uchmanowicz I. Frailty Syndrome in Older Adults with Cardiovascular Diseases-What Do We Know and What Requires Further Research? INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2022; 19:ijerph19042234. [PMID: 35206422 PMCID: PMC8872246 DOI: 10.3390/ijerph19042234] [Citation(s) in RCA: 12] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 12/18/2021] [Revised: 02/08/2022] [Accepted: 02/14/2022] [Indexed: 02/07/2023]
Abstract
Cardiovascular diseases (CVD) affect 60% of people over 60 years of age and are one of the main causes of death in the world. Diagnosed cardiovascular disease also triples the likelihood of Frailty syndrome (FS). FS has become increasingly relevant in cardiology and cardiac surgery and occurs in a significant number of patients with CVD, with prevalence ranging from 25% to 62%. Viewed in a multidimensional, biopsychosocial perspective, FS increases a patient's vulnerability, making them susceptible to several adverse clinical outcomes. Frailty syndrome also is a predictor of mortality in patients with CVD regardless of age, severity of disease, multi-morbidity, and disability. Frailty syndrome potentially can be prevented in patients with CVD and its early identification is important to avoid the development of disability, dependence on others and reduced quality of life. The aim of this paper is to show the relationship between FS and specific CVDs (coronary artery disease, hypertension, atrial fibrillation, heart failure) and cardiac procedures (device implantation, cardiac surgery, and transcatheter aortic valve implantation). Furthermore, we highlight those areas that require further research to fully understand the relationship between FS and CVD and to be able to minimize or prevent its adverse effects.
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Affiliation(s)
- Marta Wleklik
- Department of Nursing and Obstetrics, Faculty of Health Sciences, Wroclaw Medical University, 51-618 Wroclaw, Poland; (M.W.); (M.L.); (I.U.)
- Institute of Heart Diseases, University Hospital, 50-566 Wroclaw, Poland
| | - Quin Denfeld
- School of Nursing, Oregon Health and Science University, Portland, OR 97239, USA;
| | - Magdalena Lisiak
- Department of Nursing and Obstetrics, Faculty of Health Sciences, Wroclaw Medical University, 51-618 Wroclaw, Poland; (M.W.); (M.L.); (I.U.)
- Institute of Heart Diseases, University Hospital, 50-566 Wroclaw, Poland
| | - Michał Czapla
- Institute of Heart Diseases, University Hospital, 50-566 Wroclaw, Poland
- Laboratory for Experimental Medicine and Innovative Technologies, Department of Emergency Medical Service, Wroclaw Medical University, 51-616 Wroclaw, Poland
- Correspondence:
| | - Marta Kałużna-Oleksy
- 1st Department of Cardiology, University of Medical Sciences in Poznan, 61-848 Poznan, Poland;
| | - Izabella Uchmanowicz
- Department of Nursing and Obstetrics, Faculty of Health Sciences, Wroclaw Medical University, 51-618 Wroclaw, Poland; (M.W.); (M.L.); (I.U.)
- Institute of Heart Diseases, University Hospital, 50-566 Wroclaw, Poland
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Muthiah K, Wilhelm K, Robson D, Raju H, Aili SR, Jha SR, Pierce R, Fritis-Lamora R, Montgomery E, Gorrie N, Deveza R, Brennan X, Schnegg B, Jabbour A, Kotlyar E, Keogh AM, Bart N, Conellan M, Iyer A, Watson A, Granger E, Jansz PC, Hayward C, Macdonald PS. Impact of frailty on mortality and morbidity in bridge to transplant recipients of contemporary durable mechanical circulatory support. J Heart Lung Transplant 2022; 41:829-839. [DOI: 10.1016/j.healun.2022.02.008] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2021] [Revised: 01/30/2022] [Accepted: 02/14/2022] [Indexed: 11/25/2022] Open
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23
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Villa C, Greenberg JW, Morales DL. Mechanical Support for the Failing Single Ventricle After Fontan. JTCVS Tech 2022; 13:174-181. [PMID: 35713590 PMCID: PMC9195612 DOI: 10.1016/j.xjtc.2021.12.019] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/25/2021] [Accepted: 12/04/2021] [Indexed: 11/30/2022] Open
Affiliation(s)
| | | | - David L.S. Morales
- Address for reprints: David L. S. Morales, MD, Pediatric Cardiothoracic Surgery, The Heart Institute, Cincinnati Children's Hospital Medical Center, The University of Cincinnati College of Medicine, 3333 Burnet Ave – MLC 2004, Cincinnati, OH 45229.
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Roehrich L, Sündermann SH, Just IA, Kopp Fernandes L, Stein J, Solowjowa N, Mulzer J, Mueller M, Hummel M, Knierim J, Potapov E, Falk V, Schoenrath F. Comparison of feasibility and results of frailty assessment methods prior to left ventricular assist device implantation. ESC Heart Fail 2022; 9:1038-1049. [PMID: 34994094 PMCID: PMC8934953 DOI: 10.1002/ehf2.13764] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2021] [Revised: 11/07/2021] [Accepted: 12/02/2021] [Indexed: 12/12/2022] Open
Abstract
AIMS Assessing frailty and sarcopenia is considered a valuable cornerstone of perioperative risk stratification in advanced heart failure patients. The lack of an international consensus on a diagnostic standard impedes its implementation in the clinical routine. This study aimed to compare the feasibility and prognostic impact of different assessment tools in patients undergoing continuous-flow left ventricular assist device (cf-LVAD) implantation. METHODS AND RESULTS We prospectively compared feasibility and prognostic values of six frailty/sarcopenia assessment methods in 94 patients prior to cf-LVAD implantation: bioelectrical impedance analysis (BIA), computed tomography (CT)-based measurement of two muscle areas/body surface area [erector spinae muscle (TMESA/BSA) and iliopsoas muscle (TPA/BSA)], physical performance tests [grip strength, 6 min walk test (6MWT)] and Rockwood Clinical Frailty Scale (RCFS). Six-month mortality and/or prolonged ventilation time >95 h was defined as the primary endpoint. BIA and CT showed full feasibility (100%); physical performance and RCFS was limited due to patients' clinical status (feasibility: 87% grip strength, 62% 6MWT, 88% RCFS). Phase angle derived by BIA showed the best results regarding the prognostic value for 6 month mortality and/or prolonged ventilation time >95 h (odds ratio (OR) 0.66 [95% confidence interval (CI): 0.46-0.92], P = 0.019; area under the curve (AUC) 0.65). It provided incremental value to the clinical risk assessment of EuroSCORE II: C-index of the combined model was 0.75 [95% CI; 0.651-0.848] compared with C-index of EuroSCORE II alone, which was 0.73 (95% CI: 0.633-0.835). Six-month survival was decreased in patients with reduced body cell mass derived by BIA or reduced muscle area in the CT scan compared with patients with normal values: body cell mass 65% (95% CI: 51.8-81.6%) vs. 83% (95% CI: 74.0-93.9%); P = 0.03, TMESA/BSA 65% (95% CI: 51.2-82.2%) vs. 82% (95% CI: 73.2-93.0%); P = 0.032 and TPA/BSA 66% (95% CI: 53.7-81.0%) vs. 85% (95% CI: 75.0-95.8%); P = 0.035. CONCLUSIONS Bioelectrical impedance analysis parameters and CT measurements were shown to be suitable to predict 6-month mortality and/or prolonged ventilation time >95 h in patients with advanced heart failure prior to cf-LVAD implantation. Phase angle had the best predictive capacity and sarcopenia diagnosed by reduced body cell mass in BIA or muscle area in CT was associated with a decreased 6 month survival.
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Affiliation(s)
- Luise Roehrich
- Department of Cardiothoracic and Vascular Surgery, German Heart Center Berlin, Augustenburger Platz 1, Berlin, 13353, Germany.,DZHK (German Centre for Cardiovascular Research), Partner Site Berlin, Berlin, Germany.,German Heart Foundation, Frankfurt am Main, Germany
| | - Simon H Sündermann
- Department of Cardiothoracic and Vascular Surgery, German Heart Center Berlin, Augustenburger Platz 1, Berlin, 13353, Germany.,DZHK (German Centre for Cardiovascular Research), Partner Site Berlin, Berlin, Germany.,Department of Cardiovascular Surgery, Charité-Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt Universität zu Berlin, Berlin, Germany
| | - Isabell Anna Just
- Department of Cardiothoracic and Vascular Surgery, German Heart Center Berlin, Augustenburger Platz 1, Berlin, 13353, Germany.,DZHK (German Centre for Cardiovascular Research), Partner Site Berlin, Berlin, Germany
| | - Laurenz Kopp Fernandes
- Department of Cardiothoracic and Vascular Surgery, German Heart Center Berlin, Augustenburger Platz 1, Berlin, 13353, Germany
| | - Julia Stein
- Department of Cardiothoracic and Vascular Surgery, German Heart Center Berlin, Augustenburger Platz 1, Berlin, 13353, Germany
| | - Natalia Solowjowa
- Department of Cardiothoracic and Vascular Surgery, German Heart Center Berlin, Augustenburger Platz 1, Berlin, 13353, Germany
| | - Johanna Mulzer
- Department of Cardiothoracic and Vascular Surgery, German Heart Center Berlin, Augustenburger Platz 1, Berlin, 13353, Germany
| | - Marcus Mueller
- Department of Cardiothoracic and Vascular Surgery, German Heart Center Berlin, Augustenburger Platz 1, Berlin, 13353, Germany
| | | | - Jan Knierim
- Department of Cardiothoracic and Vascular Surgery, German Heart Center Berlin, Augustenburger Platz 1, Berlin, 13353, Germany
| | - Evgenij Potapov
- Department of Cardiothoracic and Vascular Surgery, German Heart Center Berlin, Augustenburger Platz 1, Berlin, 13353, Germany.,DZHK (German Centre for Cardiovascular Research), Partner Site Berlin, Berlin, Germany
| | - Volkmar Falk
- Department of Cardiothoracic and Vascular Surgery, German Heart Center Berlin, Augustenburger Platz 1, Berlin, 13353, Germany.,DZHK (German Centre for Cardiovascular Research), Partner Site Berlin, Berlin, Germany.,Department of Cardiovascular Surgery, Charité-Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt Universität zu Berlin, Berlin, Germany.,Department of Health Sciences and Technology, ETH Zürich, Zürich, Switzerland
| | - Felix Schoenrath
- Department of Cardiothoracic and Vascular Surgery, German Heart Center Berlin, Augustenburger Platz 1, Berlin, 13353, Germany.,DZHK (German Centre for Cardiovascular Research), Partner Site Berlin, Berlin, Germany
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Frailty as a Predictor of Postoperative Outcomes in Invasive Cardiac Surgery: A Systematic Review of Literature. J Cardiovasc Nurs 2022; 37:231-247. [PMID: 34016838 PMCID: PMC8602435 DOI: 10.1097/jcn.0000000000000821] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
Abstract
OBJECTIVES Frailty is a syndrome characterized by increased vulnerability and reduced ability to maintain homeostasis after stressful events that results in an increased risk for poor outcomes. Frailty screening could potentially be valuable in cardiac surgery risk assessment. The purpose of this review is to evaluate the current literature linking multicomponent frailty assessment and invasive cardiac surgery outcomes. METHODS We searched PubMed, EMBASE, and CINAHL; 1887 articles met the search criteria, and each was independently reviewed by 2 reviewers. RESULTS The 19 eligible studies assessed 52 291 subjects using 17 different frailty measurements. The most commonly used instruments were the Fried Frailty Phenotype and the Clinical Frailty Scale. Between 9% and 61% of participants were found to be frail in each study. All 19 studies included mortality as an outcome, 12 included surgical complications, 12 included hospital length of stay, 3 included quality of life, and 2 included functional status. Nine found statistically significant differences in survival between frail and nonfrail patients, 6 of 12 found that frail patients had a longer length of stay, 4 of 12 found that frail patients were more likely to experience major complications, and 2 of 2 found that frail patients were more likely to have a decrease in functional status. CONCLUSION Although some studies lacked power, the majority confirmed that frail patients are more likely to experience poor outcomes. Further research is needed to determine which frailty measure provides the best predictive validity and to identify interventions to mitigate the risks that major cardiac surgery poses to frail patients.
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Lala A, Shah P, Khalatbari S, Yosef M, Mountis MM, Robinson SW, Lanfear DE, Estep JD, Jeffries N, Taddei-Peters WC, Stevenson LW, Richards B, Mann DL, Mancini DM, Stewart GC, Aaronson KD. Frailty Measures of Patient-reported Activity and Fatigue May Predict 1-year Outcomes in Ambulatory Advanced Heart Failure: A Report From the REVIVAL Registry. J Card Fail 2021; 28:765-774. [PMID: 34961663 DOI: 10.1016/j.cardfail.2021.10.014] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/25/2021] [Revised: 10/30/2021] [Accepted: 10/30/2021] [Indexed: 11/26/2022]
Abstract
BACKGROUND The Fried Frailty Phenotype predicts adverse outcomes in geriatric populations, but has not been well-studied in advanced heart failure (HF). The Registry Evaluation of Vital Information for Ventricular Assist Devices (VADs) in Ambulatory Life (REVIVAL) study prospectively collected frailty measures in patients with advanced HF to determine relevant assessments and their impact on clinical outcomes. METHODS AND RESULTS HF-Fried Frailty was defined by 5 baseline components (1 point each): (1) weakness: hand grip strength less than 25% of body weight; (2) slowness based on time to walk 15 feet; (3) weight loss of more than 10 lbs in the past year; (4) inactivity; and (5) exhaustion, both assessed by the Kansas City Cardiomyopathy Questionnaire. A score of 0 or 1 was deemed nonfrail, 2 prefrail, and 3 or greater was considered frail. The primary composite outcome was durable mechanical circulatory support implantation, cardiac transplant or death at 1 year. Event-free survival for each group was determined by the Kaplan-Meier method and the hazard of prefrailty and frailty were compared with nonfrailty with proportional hazards modeling. Among 345 patients with all 5 frailty domains assessed, frailty was present in 17%, prefrailty in 40%, and 43% were nonfrail, with 67% (n = 232) meeting the criteria based on inactivity and 54% (n = 186) for exhaustion. Frail patients had an increased risk of the primary composite outcome (unadjusted hazard ratio [HR] 2.82, 95% confidence interval [CI] 1.52-5.24; adjusted HR 3.41, 95% CI 1.79-6.52), as did prefrail patients (unadjusted HR 1.97, 95% CI 1.14-3.41; adjusted HR 2.11, 95% CI 1.21-3.66) compared with nonfrail patients, however, the predictive value of HF-Fried Frailty criteria was modest (Harrel's C-statistic of 0.603, P = .004). CONCLUSIONS The HF-Fried Frailty criteria had only modest predictive power in identifying ambulatory patients with advanced HF at high risk for durable mechanical circulatory support, transplant, or death within 1 year, driven primarily by assessments of inactivity and exhaustion. Focus on these patient-reported measures may better inform clinical trajectories in this population.
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Affiliation(s)
- Anuradha Lala
- Zena and Weil Cardiovascular Institute, Mount Sinai Hospital, Icahn School of Medicine, New York, New York; Department of Population Health Science and Policy, Icahn School of Medicine at Mount Sinai, New York, New York.
| | - Palak Shah
- Heart Failure, Mechanical Circulatory Support and Transplant, Inova Heart and Vascular Institute, Falls Church, Virginia
| | - Shokoufeh Khalatbari
- Michigan Institute for Clinical and Health Research, University of Michigan, Ann Arbor, Michigan
| | - Matheos Yosef
- Michigan Institute for Clinical and Health Research, University of Michigan, Ann Arbor, Michigan
| | - Maria M Mountis
- Division of Cardiovascular Medicine, Cleveland Clinic, Cleveland, Ohio
| | | | - David E Lanfear
- Heart and Vascular Institute, Henry Ford Hospital, Detroit, Michigan
| | - Jerry D Estep
- Division of Cardiovascular Medicine, Cleveland Clinic, Cleveland, Ohio
| | - Neal Jeffries
- National Heart, Lung, and Blood Institute, Bethesda, Maryland
| | | | - Lynne W Stevenson
- Department of Medicine, Division of Cardiology, Vanderbilt University, Nashville, Tennessee
| | - Blair Richards
- Michigan Institute for Clinical and Health Research, University of Michigan, Ann Arbor, Michigan
| | - Douglas L Mann
- Division of Cardiovascular Medicine, Washington University School of Medicine, St. Louis, Missouri
| | - Donna M Mancini
- Zena and Weil Cardiovascular Institute, Mount Sinai Hospital, Icahn School of Medicine, New York, New York; Department of Population Health Science and Policy, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Garrick C Stewart
- Division of Cardiovascular Medicine, Brigham and Women's Hospital, Boston, Massachusetts
| | - Keith D Aaronson
- Division of Cardiovascular Medicine, University of Michigan, Ann Arbor, Michigan
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Aili SR, Lo P, Villanueva JE, Joshi Y, Emmanuel S, Macdonald PS. Prevention and Reversal of Frailty in Heart Failure - A Systematic Review. Circ J 2021; 86:14-22. [PMID: 34707071 DOI: 10.1253/circj.cj-21-0819] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
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.
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Affiliation(s)
| | - Phillip Lo
- Heart Transplant Unit, St Vincent's Hospital.,Victor Chang Cardiac Research Institute.,Faculty of Medicine, University of New South Wales
| | | | - Yashutosh Joshi
- Heart Transplant Unit, St Vincent's Hospital.,Victor Chang Cardiac Research Institute.,Faculty of Medicine, University of New South Wales
| | - Sam Emmanuel
- Faculty of Medicine, University of Notre Dame.,Heart Transplant Unit, St Vincent's Hospital.,Victor Chang Cardiac Research Institute.,Faculty of Medicine, University of New South Wales
| | - Peter S Macdonald
- Heart Transplant Unit, St Vincent's Hospital.,Victor Chang Cardiac Research Institute.,Faculty of Medicine, University of New South Wales
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28
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Sugimura Y, Sipahi NF, Immohr MB, Yilmaz E, Aissa J, Boeken U, Aubin H, Lichtenberg A, Akhyari P, Dalyanoglu H. Effect of preoperative erector spinae muscles mass on postoperative outcomes in patients with left ventricular assist devices. J Card Surg 2021; 37:297-304. [PMID: 34672025 DOI: 10.1111/jocs.16100] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2021] [Revised: 10/03/2021] [Accepted: 10/14/2021] [Indexed: 11/30/2022]
Abstract
BACKGROUND Frailty influences the postoperative outcomes in patients undergoing left ventricular assist device (LVAD) implantation. Recently, erector spinae muscle (ESM) mass has been proposed as a parameter to assess frailty accurately. Thus, the purpose of the present study was to evaluate whether preoperative ESM mass is associated with short- and long-term clinical outcomes in patients with LVAD. METHODS A total of 119 consecutive patients with LVAD were enrolled between January 2010 and October 2017 at a single heart center. The ESM area, ESM index, and Hounsfield units (HU) of the ESM were calculated by computed tomography for preoperative ESM mass evaluation. We then statistically evaluated the in-hospital mortality, major adverse cardiovascular events (MACE), duration of hospital stay, and long-term survival. RESULTS In a multivariate Cox regression analysis, ESM mass indicated no effect on all clinical outcomes. In addition, the ESM area presented a weak but significant negative linear correlation only with the duration of hospital stay (r = -0.21, p < .05). In contrast, the Model For End-stage Liver Disease (MELD) score and preoperative venous-arterial extracorporeal membrane oxygenation (va-ECMO) were significant predictive factors for in-hospital mortality (MELD score: p < .001, hazard ratio [HR] 1.1; preoperative va-ECMO: p < .01, HR 2.72) and MACE (MELD score: p < .001, HR 1.07; preoperative va-ECMO: p < .005, HR 2.62). CONCLUSION Preoperative ESM mass might predict the length of hospital stay in patients undergoing LVAD implantation. In contrast, it had no effect on MACE, in-hospital mortality, or long-term survival in this study.
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Affiliation(s)
- Yukiharu Sugimura
- Department of Cardiac Surgery and Research Group for Experimental Surgery, Medical Faculty, Heinrich Heine University Hospital, Düsseldorf, Germany
| | - Nihat F Sipahi
- Department of Cardiac Surgery and Research Group for Experimental Surgery, Medical Faculty, Heinrich Heine University Hospital, Düsseldorf, Germany
| | - Moritz B Immohr
- Department of Cardiac Surgery and Research Group for Experimental Surgery, Medical Faculty, Heinrich Heine University Hospital, Düsseldorf, Germany
| | - Esma Yilmaz
- Department of Cardiac Surgery and Research Group for Experimental Surgery, Medical Faculty, Heinrich Heine University Hospital, Düsseldorf, Germany
| | - Joel Aissa
- Department of Diagnostic and Interventional Radiology, Medical Faculty, Heinrich Heine University, Düsseldorf, Germany
| | - Udo Boeken
- Department of Cardiac Surgery and Research Group for Experimental Surgery, Medical Faculty, Heinrich Heine University Hospital, Düsseldorf, Germany
| | - Hug Aubin
- Department of Cardiac Surgery and Research Group for Experimental Surgery, Medical Faculty, Heinrich Heine University Hospital, Düsseldorf, Germany
| | - Artur Lichtenberg
- Department of Cardiac Surgery and Research Group for Experimental Surgery, Medical Faculty, Heinrich Heine University Hospital, Düsseldorf, Germany
| | - Payam Akhyari
- Department of Cardiac Surgery and Research Group for Experimental Surgery, Medical Faculty, Heinrich Heine University Hospital, Düsseldorf, Germany
| | - Hannan Dalyanoglu
- Department of Cardiac Surgery and Research Group for Experimental Surgery, Medical Faculty, Heinrich Heine University Hospital, Düsseldorf, Germany
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Frailty Assessment in Heart Failure and Ventricular Assist Device Populations: A Review from the United States. Heart Lung 2021; 50:941-952. [PMID: 34433112 DOI: 10.1016/j.hrtlng.2021.07.015] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2021] [Revised: 07/28/2021] [Accepted: 07/29/2021] [Indexed: 01/30/2023]
Abstract
IMPORTANCE Post-operative risk is increased with frail individuals undergoing cardiac surgery. Yet, there is no consensus for frailty assessment prior to durable left ventricular assist device (dLVAD) evaluation. OBJECTIVE The objectives of this integrative review were to describe frailty measures, examine psychometrics of measures used, and identify variables related to frailty in heart failure with reduced ejection fraction (HFrEF) and dLVAD populations. DESIGN, SETTING, PARTICIPANTS PubMed, CINAHL, and Embase databases were searched for terms related to frailty, HFrEF and dLVAD that met inclusion criteria. RESULTS Fourteen articles met inclusion criteria. Frailty was inconsistently defined. The Fried Phenotype Criteria was the most widely used approach to measurement. Validity was reported in all articles. Variables related to frailty included readmissions, higher mortality and increased adverse events. CONCLUSION There was variability in frailty definition and frailty measurement across studies. Further research in HFrEF and dLVAD populations is needed for frailty evaluation.
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30
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Davis MR, Lee CS, Corcoran A, Gupta N, Uchmanowicz I, Denfeld QE. Gender differences in the prevalence of frailty in heart failure: A systematic review and meta-analysis. Int J Cardiol 2021; 333:133-140. [PMID: 33657397 PMCID: PMC8107129 DOI: 10.1016/j.ijcard.2021.02.062] [Citation(s) in RCA: 33] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/08/2020] [Revised: 01/29/2021] [Accepted: 02/22/2021] [Indexed: 12/14/2022]
Abstract
OBJECTIVES This study quantitatively synthesized literature to identify gender differences in the prevalence of frailty in heart failure (HF). BACKGROUND The intersection of frailty and HF continues to garner interest. Almost half of patients with HF are frail; however, gender differences in frailty in HF are poorly understood. METHODS We performed a literature search to identify studies that reported prevalence of frailty by gender in HF. Random-effects meta-analysis was used to quantify the relative and absolute risk of frailty in women compared with men with HF, overall, and by Physical and Multidimensional Frailty measures. Meta-regression was performed to examine the influence of study age and functional class on relative risk in HF. RESULTS Twenty-nine studies involving 8854 adults with HF were included. Overall in HF, women had a 26% higher relative risk of being frail compared with men (95% CI = 1.14-1.38, z = 4.69, p < 0.001, I2 = 76.5%). The overall absolute risk for women compared to men with HF being frail was 10% (95% CI = 0.06-0.15, z = 4.41, p < 0.001). The relative risk of frailty was slightly higher among studies that used Physical measures (relative risk = 1.27, p < 0.001) compared with studies that used Multidimensional measures (relative risk = 1.24, p = 0.024). There were no significant relationships between relative risk and either study age or functional class. CONCLUSIONS In HF, frailty affects women significantly more than men. Future work should focus on elucidating potential causes of gender differences in frailty in HF.
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Affiliation(s)
- Mary Roberts Davis
- Oregon Health & Science University School of Nursing, 3455 S.W. U.S. Veterans Hospital Road, Portland, OR 97239-2941, USA.
| | - Christopher S Lee
- Boston College William F. Connell School of Nursing, 140 Commonwealth Avenue, Boston, MA 02467, USA.
| | - Amy Corcoran
- Oregon Health & Science University, Knight Cardiovascular Institute, 808 S.W. Campus Drive, Portland, OR 97239, USA.
| | - Nandita Gupta
- Oregon Health & Science University, Knight Cardiovascular Institute, 808 S.W. Campus Drive, Portland, OR 97239, USA.
| | - Izabella Uchmanowicz
- Department of Clinical Nursing, Wrocław Medical University, K. Bartla 5, 51-618 Wroclaw, Poland.
| | - Quin E Denfeld
- Oregon Health & Science University School of Nursing, 3455 S.W. U.S. Veterans Hospital Road, Portland, OR 97239-2941, USA.
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31
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Villa CR, Lorts A, Morales DLS. Ventricular Assist Device Therapy in the Fontan Circulation. Semin Thorac Cardiovasc Surg Pediatr Card Surg Annu 2021; 24:19-25. [PMID: 34116777 DOI: 10.1053/j.pcsu.2021.01.001] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2020] [Revised: 01/04/2021] [Accepted: 01/14/2021] [Indexed: 12/25/2022]
Abstract
The number of Fontan patients with circulatory failure and systolic dysfunction is growing rapidly. The last decade has demonstrated that ventricular assist device (VAD) is an effective therapy in properly selected patients. Herein, we discuss the current approach to patient selection, implantation, and patient management.
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Affiliation(s)
- Chet R Villa
- The Heart Institute, Cincinnati Children's Hospital Medical Center, University of Cincinnati College of Medicine, Cincinnati, Ohio
| | - Angela Lorts
- The Heart Institute, Cincinnati Children's Hospital Medical Center, University of Cincinnati College of Medicine, Cincinnati, Ohio
| | - David L S Morales
- The Heart Institute, Cincinnati Children's Hospital Medical Center, University of Cincinnati College of Medicine, Cincinnati, Ohio.
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Ju C, Zhou J, Lee S, Tan MS, Liu T, Bazoukis G, Jeevaratnam K, Chan EWY, Wong ICK, Wei L, Zhang Q, Tse G. Derivation of an electronic frailty index for predicting short-term mortality in heart failure: a machine learning approach. ESC Heart Fail 2021; 8:2837-2845. [PMID: 34080784 PMCID: PMC8318426 DOI: 10.1002/ehf2.13358] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2020] [Revised: 02/15/2021] [Accepted: 03/29/2021] [Indexed: 12/12/2022] Open
Abstract
Aims Frailty may be found in heart failure patients especially in the elderly and is associated with a poor prognosis. However, assessment of frailty status is time‐consuming, and the electronic frailty indices developed using health records have served as useful surrogates. We hypothesized that an electronic frailty index developed using machine learning can improve short‐term mortality prediction in patients with heart failure. Methods and results This was a retrospective observational study that included patients admitted to nine public hospitals for heart failure from Hong Kong between 2013 and 2017. Age, sex, variables in the modified frailty index, Deyo's Charlson co‐morbidity index (≥2), neutrophil‐to‐lymphocyte ratio (NLR), and prognostic nutritional index at baseline were analysed. Gradient boosting, which is a supervised sequential ensemble learning algorithm with weak prediction submodels (typically decision trees), was applied to predict mortality. Variables were ranked in the order of importance with a total score of 100 and used to build the frailty models. Comparisons were made with decision tree and multivariable logistic regression. A total of 8893 patients (median: age 81, Q1–Q3: 71–87 years old) were included, in whom 9% had 30 day mortality and 17% had 90 day mortality. Prognostic nutritional index, age, and NLR were the most important variables predicting 30 day mortality (importance score: 37.4, 32.1, and 20.5, respectively) and 90 day mortality (importance score: 35.3, 36.3, and 14.6, respectively). Gradient boosting significantly outperformed decision tree and multivariable logistic regression. The area under the curve from a five‐fold cross validation was 0.90 for gradient boosting and 0.87 and 0.86 for decision tree and logistic regression in predicting 30 day mortality. For the prediction of 90 day mortality, the area under the curve was 0.92, 0.89, and 0.86 for gradient boosting, decision tree, and logistic regression, respectively. Conclusions The electronic frailty index based on co‐morbidities, inflammation, and nutrition information can readily predict mortality outcomes. Their predictive performances were significantly improved by gradient boosting techniques.
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Affiliation(s)
- Chengsheng Ju
- Research Department of Practice and Policy, School of Pharmacy, University College London, London, UK
| | - Jiandong Zhou
- School of Data Science, City University of Hong Kong, Hong Kong SAR, China
| | - Sharen Lee
- Cardiovascular Analytics Group, Laboratory of Cardiovascular Physiology, LKS Institute of Health Sciences, Chinese University of Hong Kong, Hong Kong SAR, China
| | | | - Tong Liu
- Tianjin Key Laboratory of Ionic-Molecular Function of Cardiovascular Disease, Department of Cardiology, Tianjin Institute of Cardiology, Second Hospital of Tianjin Medical University, Tianjin, China
| | - George Bazoukis
- Second Department of Cardiology, Evangelismos General Hospital, Athens, Greece
| | | | - Esther W Y Chan
- Centre for Safe Medication Practice and Research, Department of Pharmacology and Pharmacy, The University of Hong Kong, Hong Kong SAR, China
| | - Ian Chi Kei Wong
- Research Department of Practice and Policy, School of Pharmacy, University College London, London, UK.,Centre for Safe Medication Practice and Research, Department of Pharmacology and Pharmacy, The University of Hong Kong, Hong Kong SAR, China
| | - Li Wei
- Research Department of Practice and Policy, School of Pharmacy, University College London, London, UK
| | - Qingpeng Zhang
- School of Data Science, City University of Hong Kong, Hong Kong SAR, China
| | - Gary Tse
- Tianjin Key Laboratory of Ionic-Molecular Function of Cardiovascular Disease, Department of Cardiology, Tianjin Institute of Cardiology, Second Hospital of Tianjin Medical University, Tianjin, China.,Faculty of Health and Medical Sciences, University of Surrey, Guildford, UK
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Ambulatory advanced heart failure patients: timing of mechanical circulatory support - delaying the inevitable? Curr Opin Cardiol 2021; 36:186-197. [PMID: 33395078 DOI: 10.1097/hco.0000000000000831] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
PURPOSE OF REVIEW Current indications for continuous-flow left ventricular assist device (cfLVAD) implantation is for patients in cardiogenic shock or inotrope-dependent advanced heart failure. Risk stratification of noninotrope dependent ambulatory advanced heart failure patients is a subject of registries designed to help shared-decision making by clinicians and patients regarding the optimal timing of mechanical circulatory support (MCS). RECENT FINDINGS The Registry Evaluation of Vital Information for VADs in Ambulatory Life enrolled ambulatory noninotrope dependent advanced systolic heart failure patients who had 25% annualized risk of death, MCS, or heart transplantation (HT). Freedom from composite clinical outcome at 1-year follow-up was 23.5% for the entire cohort. Seattle Heart Failure Model Score and Natriuretic pepides were predictors with modest discriminatory power. Interagency Registry for Mechanically Assisted Circulatory Support (INTERMACS) profile 4 patients had the highest risk (3.7-fold) of death, MCS or HT compared to INTERMACS profile 7. SUMMARY We propose individualized risk stratification for noninotrope dependent ambulatory advanced heart failure patients and include serial changes in end-organ function, nutritional parameters, frailty assessment, echocardiographic and hemodynamic data. The clinical journey of a patient with advanced heart failure should be tracked and discussed at each clinic visit for shared decision-making regarding timing of cfLVAD.
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Cumulative Deficits Frailty Index Predicts Outcomes for Solid Organ Transplant Candidates. Transplant Direct 2021; 7:e677. [PMID: 34113716 PMCID: PMC8183975 DOI: 10.1097/txd.0000000000001094] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/03/2020] [Revised: 09/27/2020] [Accepted: 10/13/2020] [Indexed: 12/15/2022] Open
Abstract
Supplemental Digital Content is available in the text. Despite comprehensive multidisciplinary candidacy assessments to determine appropriateness for solid organ transplantation, limitations persist in identifying candidates at risk of adverse outcomes. Frailty measures may help inform candidacy evaluation. Our main objective was to create a solid organ transplant frailty index (FI), using the cumulative deficits model, from data routinely collected during candidacy assessments. Secondary objectives included creating a social vulnerability index (SVI) from assessment data and evaluating associations between the FI and assessment, waitlist, and posttransplant outcomes.
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Abstract
Frailty has been defined as a state of increased vulnerability due to a decline in the reserve and function of multiple physiological systems. Initially conceived as a geriatric syndrome indicative of physiological aging, it is now apparent that frailty can also be observed as a manifestation of chronic disease states including heart failure. Estimates of the prevalence of frailty in heart failure vary according to the age of the study population and the frailty instrument used, however multiple studies have identified frailty to be prevalent in patients with advanced heart failure including those who are referred for heart transplantation. Frailty is emerging as an independent predictor of mortality both before and after bridge-to-transplant ventricular assist device (BTT VAD) implantation and heart transplantation. Frailty is also predictive of prolonged hospitalization following these procedures. Heart failure-associated frailty is a dynamic state. While reversibility of frailty can be anticipated in younger heart failure patients, predicting the reversibility of frailty is more challenging in older patients who often have multiple comorbidities that may contribute to the frailty syndrome. Prehabilitation is a promising approach to both preventing and reversing frailty however more research is urgently needed to establish its effectiveness in mitigating the adverse impacts of frailty on post-VAD and posttransplant morbidity and mortality.
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Validation of Cognitive Impairment in Combination With Physical Frailty as a Predictor of Mortality in Patients With Advanced Heart Failure Referred for Heart Transplantation. Transplantation 2021; 106:200-209. [PMID: 33988342 DOI: 10.1097/tp.0000000000003669] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND The aim of this study was to validate our previous finding that frailty predicts early mortality in patients with advanced heart failure (AHF) and that including cognition in the frailty assessment enhances the prediction of mortality. METHODS Patients with AHF referred to our Transplant Unit between November 2015 and April 2020 underwent physical frailty assessment using the modified Fried physical frailty (PF) phenotype as well as cognitive assessment using the Montreal Cognitive Assessment (MOCA) to identify patients who were cognitively frail (CogF). We assessed the predictive value of the 2 frailty measures (PF ≥ 3 of 5 = frail; CogF ≥ 3 of 6 = frail) for pretransplant mortality. RESULTS 313 patients (233 male, 80 female; age 53 ± 13 years) were assessed. Of these, 224 patients (72%) were nonfrail and 89 (28%) were frail using the PF. The cognitive frailty assessment identified an additional 30 patients as frail: 119 (38%). Frail patients had significantly increased mortality as compared to nonfrail patients. Ventricular assist device and heart transplant-censored survival at 12 months was 92 ± 2 % for nonfrail and 69 ± 5% for frail patients (p < 0.0001) using the CogF instrument. CONCLUSIONS This study validates our previously published findings that frailty is prevalent in patients with advanced heart failure referred for heart transplantation. Physical frailty predicts early mortality. The addition of cognitive assessment to the physical assessment of frailty identifies an additional cohort of patients with a similarly poor prognosis.
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Kobashigawa J, Shah P, Joseph S, Olymbios M, Bhat G, Dhital K, Eisen H, Kransdorf E, Patel J, Skorka R, Pinney S, Wilson ME, Hall S. Frailty in heart transplantation: Report from the heart workgroup of a consensus conference on frailty. Am J Transplant 2021; 21:636-644. [PMID: 32659872 DOI: 10.1111/ajt.16207] [Citation(s) in RCA: 16] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2020] [Revised: 07/05/2020] [Accepted: 07/06/2020] [Indexed: 01/25/2023]
Abstract
A consensus conference on frailty in solid organ transplantation took place on February 11, 2018, to discuss the latest developments in frailty, adopt a standardized approach to assessment, and generate ideas for future research. The findings and consensus of the Frailty Heart Workgroup (American Society of Transplantation's Thoracic and Critical Care Community of Practice) are presented here. Frailty is defined as a clinically recognizable state of increased vulnerability resulting from aging-associated decline in reserve and function across multiple physiologic systems such that the ability to cope with every day or acute stressors is compromised. Frailty is increasingly recognized as a distinct biologic entity that can adversely affect outcomes before and after heart transplantation. A greater proportion of patients referred for heart transplantation are older and have more complex comorbidities. However, outcomes data in the pretransplant setting, particularly for younger patients, are limited. Therefore, there is a need to develop objective frailty assessment tools for risk stratification in patients with advanced heart disease. These tools will help to determine appropriate recipient selection for advanced heart disease therapies including heart transplantation and mechanical circulatory support, improve overall outcomes, and help distinguish frailty phenotypes amenable to intervention.
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Affiliation(s)
- Jon Kobashigawa
- Cedars-Sinai Smidt Heart Institute, Los Angeles, California, USA
| | - Palak Shah
- Inova Heart and Vascular Institute, Falls Church, Virginia, USA
| | - Susan Joseph
- Baylor University Medical Center, Dallas, Texas, USA
| | - Michael Olymbios
- Cedars-Sinai Smidt Heart Institute, Los Angeles, California, USA
| | - Geetha Bhat
- Advocate Christ Medical Center, Oak Lawn, Illinois, USA
| | | | - Howard Eisen
- Drexel University, Philadelphia, Pennsylvania, USA
| | - Evan Kransdorf
- Cedars-Sinai Smidt Heart Institute, Los Angeles, California, USA
| | - Jignesh Patel
- Cedars-Sinai Smidt Heart Institute, Los Angeles, California, USA
| | - Rafael Skorka
- Cedars-Sinai Smidt Heart Institute, Los Angeles, California, USA
| | - Sean Pinney
- Mount Sinai Hospital, New York, New York, USA
| | | | - Shelley Hall
- Baylor University Medical Center, Dallas, Texas, USA
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Di Nora C, Guidetti F, Livi U, Antonini-Canterin F. Role of Cardiac Rehabilitation After Ventricular Assist Device Implantation. Heart Fail Clin 2021; 17:273-278. [PMID: 33673951 DOI: 10.1016/j.hfc.2021.01.008] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
Patients with heart failure suffered by a complex syndrome, where the filling of the ventricle or ejection of the blood is impaired. In this setting, the exercise capacity decreases for many reasons, one of them being the insufficient oxygen transfer due to reduced cardiac output and anemia. Ventricular assist device has emerged as a durable and safe therapy for patients with end-stage heart failure. The benefits of cardiac rehabilitation in ventricular assist device patients are enormous: the first aim is to progressively reduce the physical and functional impairments of these patients, so that they will be able to resume meaningful daily activities.
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Affiliation(s)
- Concetta Di Nora
- Department of Cardiothoracic Science, Azienda Sanitaria Universitaria Integrata di Udine, Italy.
| | - Federica Guidetti
- Department of Cardiology, University Heart Center, University Hospital Zurich, Zurich, Switzerland
| | - Ugolino Livi
- Department of Cardiothoracic Science, Azienda Sanitaria Universitaria Integrata di Udine, Italy
| | - Francesco Antonini-Canterin
- Cardiac Prevention and Rehabilitation Unit, Highly Specialized Rehabilitation Hospital, Motta di Livenza, Italy
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Pandey A, Kitzman D, Whellan DJ, Duncan PW, Mentz RJ, Pastva AM, Nelson MB, Upadhya B, Chen H, Reeves GR. Frailty Among Older Decompensated Heart Failure Patients: Prevalence, Association With Patient-Centered Outcomes, and Efficient Detection Methods. JACC-HEART FAILURE 2020; 7:1079-1088. [PMID: 31779931 DOI: 10.1016/j.jchf.2019.10.003] [Citation(s) in RCA: 52] [Impact Index Per Article: 13.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/03/2019] [Revised: 10/07/2019] [Accepted: 10/07/2019] [Indexed: 12/15/2022]
Abstract
OBJECTIVES This study sought to assess the prevalence of frailty, its associations with physical function, quality of life (QoL), cognition, and depression and to investigate more efficient methods of detection in older patients hospitalized with acute decompensated heart failure (ADHF). BACKGROUND In contrast to the outpatient population with chronic HF, much less is known regarding frailty in older, hospitalized patients with ADHF. METHODS Older hospitalized patients (N = 202) with ADHF underwent assessment of frailty (using Fried criteria), short physical performance battery (SPPB), 6-min walk test (6-MWT) distance, quality of life (QoL using the Kansas City Cardiomyopathy Questionnaire), cognition (using the Montreal Cognition Assessment), and depression (using the Geriatric Depression Screen [GDS]). The associations of frailty with these patient-centered outcomes were assessed by using adjusted linear regression models. Novel strategies to identify frailty were examined. RESULTS A total of 50% of older, hospitalized patients with ADHF were frail, 48% were pre-frail, and 2% were non-frail. Female sex, burden of comorbidity, and prior HF hospitalization were significantly associated with higher likelihood of frailty. Frailty (vs. pre-frail status) was associated with a significantly worse SPPB score (5 ± 2.2 vs. 7 ± 2.4, respectively), 6-MWT distance (143 ± 79 m vs. 221 ± 99 m, respectively), QoL (35 ± 19 vs. 46 ± 21, respectively), and more depression (GDS score: 5.5 ± 3.5 vs. 4.2 ± 3.3, respectively) but similar cognition. These associations were unchanged after adjustment for age, sex, race, total comorbidities, and body mass index. Slow gait speed plus low physical activity signaled frailty status as well (C-statistic = 0.85). CONCLUSIONS Ninety-eight percent of older, hospitalized patients with ADHF are frail or pre-frail. Frailty (vs. pre-frail status) is associated with worse physical function, QoL, comorbidity, and depression. The simple 4-m walk test combined with self-reported physical activity may quickly and efficiently identify frailty in older patients with ADHF.
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Affiliation(s)
- Ambarish Pandey
- Division of Cardiology, Department of Internal Medicine, University of Texas Southwestern Medical Center, Dallas, Texas
| | - Dalane Kitzman
- Department of Internal Medicine, Section of Cardiovascular Medicine, Wake Forest School of Medicine, Winston-Salem, North Carolina
| | - David J Whellan
- Department of Medicine, Thomas Jefferson University, Philadelphia, Pennsylvania
| | - Pamela W Duncan
- Department of Neurology, Wake Forest School of Medicine, Winston-Salem, North Carolina
| | - Robert J Mentz
- Department of Medicine, Cardiology Division, Duke University School of Medicine, Durham, North Carolina
| | - Amy M Pastva
- Department of Medicine and Orthopedic Surgery, Duke University School of Medicine, Durham, North Carolina
| | - M Benjamin Nelson
- Department of Internal Medicine, Section of Cardiovascular Medicine, Wake Forest School of Medicine, Winston-Salem, North Carolina
| | - Bharathi Upadhya
- Department of Internal Medicine, Section of Cardiovascular Medicine, Wake Forest School of Medicine, Winston-Salem, North Carolina
| | - Haiying Chen
- Department of Biostatistics and Data Science, Wake Forest School of Medicine, Winston-Salem, North Carolina
| | - Gordon R Reeves
- Heart and Vascular Institute, Novant Health, Charlotte, North Carolina.
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Uchmanowicz I, Lee CS, Vitale C, Manulik S, Denfeld QE, Uchmanowicz B, Rosińczuk J, Drozd M, Jaroch J, Jankowska EA. Frailty and the risk of all-cause mortality and hospitalization in chronic heart failure: a meta-analysis. ESC Heart Fail 2020; 7:3427-3437. [PMID: 32955168 PMCID: PMC7754732 DOI: 10.1002/ehf2.12827] [Citation(s) in RCA: 40] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/03/2020] [Revised: 05/10/2020] [Accepted: 05/21/2020] [Indexed: 12/11/2022] Open
Abstract
To estimate the risk of all-cause mortality and hospitalization in frail patients with chronic heart failure (HF), a systematic search and meta-analysis was carried out to identify all prospective cohort studies conducted among adults with HF where frailty was quantified and related to the primary endpoints of all-cause mortality and/or hospitalization. Twenty-nine studies reporting the link between frailty and all-cause mortality in 18 757 patients were available for the meta-analysis, along with 11 studies, with 13 525 patients, reporting the association between frailty and hospitalization. Frailty was a predictor of all-cause mortality and hospitalization with summary hazard ratios (HRs) of 1.48 [95% confidence interval (CI): 1.31-1.65, P < 0.001] and 1.40 (95% CI: 1.27-1.54, P < 0.001), respectively. Summary HRs for all-cause mortality among frail inpatients undergoing ventricular assist device implantation, inpatients hospitalized for HF, and outpatients were 1.46 (95% CI: 1.18-1.73, P < 0.001), 1.58 (95% CI: 0.94-2.22, P = not significant), and 1.53 (95% CI: 1.28-1.78, P < 0.001), respectively. Summary HRs for all-cause mortality and frailty based on Fried's phenotype were 1.48 (95% CI: 1.03-1.93, P < 0.001) and 1.42 (95% CI: 1.05-1.79, P < 0.001) for inpatients and outpatients, respectively, and based on other frailty measures were 1.42 (95% CI: 1.12-1.72, P < 0.001) and 1.60 (95% CI: 1.43-1.77, P < 0.001) for inpatients and outpatients, respectively. Across clinical contexts, frailty in chronic HF is associated with an average of 48% and 40% increase in the hazard of all-cause mortality and hospitalization, respectively. The relationship between frailty and all-cause mortality is similar across clinical settings and comparing measurement using Fried's phenotype or other measures.
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Affiliation(s)
- Izabella Uchmanowicz
- Department of Clinical Nursing, Faculty of Health SciencesWroclaw Medical UniversityBartla 5Wroclaw51‐618Poland
| | | | - Cristiana Vitale
- Centre for Clinical and Basic Research, IRCCS San Raffaele PisanaRomeItaly
| | - Stanisław Manulik
- Department of Clinical Nursing, Faculty of Health SciencesWroclaw Medical UniversityBartla 5Wroclaw51‐618Poland
| | - Quin E. Denfeld
- Oregon Health and Science University School of NursingPortlandORUSA
| | - Bartosz Uchmanowicz
- Department of Clinical Nursing, Faculty of Health SciencesWroclaw Medical UniversityBartla 5Wroclaw51‐618Poland
| | - Joanna Rosińczuk
- Department of Clinical Nursing, Faculty of Health SciencesWroclaw Medical UniversityBartla 5Wroclaw51‐618Poland
| | - Marcin Drozd
- Department of Clinical Nursing, Faculty of Health SciencesWroclaw Medical UniversityBartla 5Wroclaw51‐618Poland
- Centre for Heart DiseasesWroclaw Medical UniversityWroclawPoland
| | - Joanna Jaroch
- Department of Clinical Nursing, Faculty of Health SciencesWroclaw Medical UniversityBartla 5Wroclaw51‐618Poland
| | - Ewa A. Jankowska
- Department of Clinical Nursing, Faculty of Health SciencesWroclaw Medical UniversityBartla 5Wroclaw51‐618Poland
- Centre for Heart DiseasesWroclaw Medical UniversityWroclawPoland
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Abstract
Population health and population health management of patients with heart failure aim to identify all patients with the condition in a population, to characterize and risk stratify subgroups of patients, to improve care delivery by leveraging technology and data so providers can improve care coordination, to engage disease management programs, and to create cost-effective health systems that reduce financial burden on patients and providers. This requires a shift in our treatment paradigm from reactive treatment to proactive primary and secondary prevention. Shifts from fee-for-service to value-based payment models promise to encourage population health.
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Affiliation(s)
- Prateeti Khazanie
- Division of Cardiology, University of Colorado School of Medicine, 12631 East 17th Avenue, Mail Stop B130, Aurora, CO 80045, USA.
| | - Larry A Allen
- Division of Cardiology, University of Colorado School of Medicine, 12631 East 17th Avenue, Mail Stop B130, Aurora, CO 80045, USA
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Left ventricular assist systems and infection-related outcomes: A comprehensive analysis of the MOMENTUM 3 trial. J Heart Lung Transplant 2020; 39:774-781. [DOI: 10.1016/j.healun.2020.03.002] [Citation(s) in RCA: 32] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2020] [Revised: 03/03/2020] [Accepted: 03/03/2020] [Indexed: 12/29/2022] Open
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Loungani RS, Mentz RJ, Agarwal R, DeVore AD, Patel CB, Rogers JG, Russell SD, Felker GM. Biomarkers in Advanced Heart Failure: Implications for Managing Patients With Mechanical Circulatory Support and Cardiac Transplantation. Circ Heart Fail 2020; 13:e006840. [PMID: 32660322 DOI: 10.1161/circheartfailure.119.006840] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/06/2023]
Abstract
Biomarkers have a well-defined role in the diagnosis and management of chronic heart failure, but their role in patients with left ventricular assist devices and cardiac transplant is uncertain. In this review, we summarize the available literature in this patient population, with a focus on clinical application. Some ubiquitous biomarkers, for example, natriuretic peptides and cardiac troponin, may assist in the diagnosis of left ventricular assist device complications and transplant rejection. Novel biomarkers focused on specific pathological processes, such as left ventricular assist device thrombosis and profiling of leukocyte activation, continue to be developed and show promise in altering the management of the advanced heart failure patient. Few biomarkers at this time have been assessed with sufficient scrutiny to warrant broad, universal application, but encouraging limited data and large potential for impact should prompt ongoing investigation.
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Affiliation(s)
- Rahul S Loungani
- Division of Cardiology, Duke University School of Medicine, Durham, NC
| | - Robert J Mentz
- Division of Cardiology, Duke University School of Medicine, Durham, NC
| | - Richa Agarwal
- Division of Cardiology, Duke University School of Medicine, Durham, NC
| | - Adam D DeVore
- Division of Cardiology, Duke University School of Medicine, Durham, NC
| | - Chetan B Patel
- Division of Cardiology, Duke University School of Medicine, Durham, NC
| | - Joseph G Rogers
- Division of Cardiology, Duke University School of Medicine, Durham, NC
| | - Stuart D Russell
- Division of Cardiology, Duke University School of Medicine, Durham, NC
| | - G Michael Felker
- Division of Cardiology, Duke University School of Medicine, Durham, NC
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Shock Team Approaches in Managing Cardiogenic Shock—Intersection Between Critical Care and Advanced Heart Failure and Transplant Cardiology. CURRENT TREATMENT OPTIONS IN CARDIOVASCULAR MEDICINE 2020. [DOI: 10.1007/s11936-020-00820-2] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
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Lemus Barrios GA, Morales Benavidez DC, López Salazar AM, Henao V, González-Robledo G. Evaluación de la fragilidad en la enfermedad cardiovascular: Un reto necesario. REVISTA COLOMBIANA DE CARDIOLOGÍA 2020. [DOI: 10.1016/j.rccar.2019.12.015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022] Open
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The Impact of Left Ventricular Assist Device Infections on Postcardiac Transplant Outcomes: A Systematic Review and Meta-Analysis. ASAIO J 2020; 65:827-836. [PMID: 30575630 DOI: 10.1097/mat.0000000000000921] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022] Open
Abstract
Left ventricular assist devices (LVADs) are associated with numerous short- and long-term complications, including infection. The impact LVAD infections have on clinical outcomes after transplantation is not well established. We sought to determine whether the presence of infection while on LVAD support negatively influences outcomes after cardiac transplantation. We searched electronic databases and bibliographies for full text studies that identified LVAD infections during support and also reported on posttransplant outcomes. A meta-analysis of posttransplant survival was conducted using a random effects model. Of 2,373 records, 13 bridge to transplant (BTT) cohort studies were selected (n = 6,631, 82% male, mean age 50.7 ± 2.7 years). A total of 6,067 records (91.5%) received transplant. There were 3,718 (56.1%) continuous-flow LVADs (CF-LVADs), 1,752 (26.4%) pulsatile LVADs, and 1,161 (17.5%) unknown type records. A total of 2,586 records (39.0%) developed LVAD infections. Patients with LVAD infections were younger (50.5 ± 1.5 vs. 51.3 ± 1.5, p = 0.02), had higher body mass indeices (BMIs) (28.4 ± 0.7 vs. 26.8 ± 0.4, p < 0.01), and longer LVAD support times (347.0 ± 157.6 days vs. 180.2 ± 106.0 days, p < 0.01). Meta-analysis demonstrated increased posttransplant mortality in those patients who had an LVAD infection (hazard ratio [HR] 1.30, 95% CI: 1.16-1.46, p < 0.001). Subgroup meta-analyses by continuous-flow and pulsatile device type demonstrated significant increased risk of death for both types of devices (HR 1.47, 95% CI: 1.22-1.76, p < 0.001 and 1.71, 95% CI: 1.19-2.45, p = 0.004, respectively). Patients who develop LVAD infections are younger, have higher BMIs and longer LVAD support times. Our data suggests that LVAD-related infections result in a 30% increase in postcardiac transplantation mortality. Strategies to prevent LVAD infections should be implemented to improve posttransplant outcomes in this high-risk population.
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Prichard R, Kershaw L, Goodall S, Davidson P, Newton PJ, Saing S, Hayward C. Costs Before and After Left Ventricular Assist Device Implant and Preceding Heart Transplant: A Cohort Study. Heart Lung Circ 2020; 29:1338-1346. [PMID: 32371031 DOI: 10.1016/j.hlc.2019.08.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2018] [Revised: 07/21/2019] [Accepted: 08/12/2019] [Indexed: 11/18/2022]
Abstract
BACKGROUND Up to 50% of heart transplant candidates require bridging with left ventricular assist devices (VAD). This study describes hospital activity and cost 1 year preceding and 1 year following VAD implant (pre-VAD) and for the year before transplant (pre-HTX). The sample comprises an Australian cohort and is the first study to investigate costs using both institutional and linked administrative data. METHODS Institutional activity was established for 77 consecutive patients actively listed for transplant between 2009 and 2012. Costs were sourced from the institution or Australian refined diagnosis groups (arDRGs) and the National Efficient Price for admissions to other public and private institutions. Data from 25/77 VAD recipients were analysed and compared with data from 52/77 pre-transplant patients. Total and per day at risk costs were assessed, as well as totals per resource. RESULTS Fifty per cent (50%) of the hospital costs in the pre-VAD year occurred during admission of VAD implant. Sixty-four per cent (64%) of costs in the pre-HTX and 38% in the pre-VAD period occurred outside the implanting centre. Costs in the year prior to VAD, $97,565 (IQR $86,907-$153,916), were significantly higher than costs accrued in the year prior to transplant, $40,250 ($13,493-$81,260), p < 0.0001. Once discharged, costs per day at risk for post-VAD patients approximated those from the pre-admission period, p = 0.16 and in the more clinically stable pre-HTX cohort, p = 0.08. CONCLUSION Compared with the year prior, VAD implant stabilised hospital cost in patients discharged home. A high proportion of the hospital costs in the pre-implant year occur outside the implanting centre and should be considered in economic models assessing the impact of VAD implant.
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Affiliation(s)
- Roslyn Prichard
- Faculty of Health, University of Technology Sydney, NSW, Australia
| | | | - Stephen Goodall
- Centre for Health Economics Research and Evaluation, University of Technology Sydney, NSW, Australia
| | - Patricia Davidson
- Johns Hopkins University, Baltimore, MD, USA; Faculty of Health, University of Technology Sydney, NSW, Australia
| | - Phillip J Newton
- Faculty of Health, University of Technology Sydney, NSW, Australia
| | - Sopany Saing
- Centre for Health Economics Research and Evaluation, University of Technology Sydney, NSW, Australia
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Abstract
RATIONALE Frailty represents an increased vulnerability to adverse health outcomes. The frailty phenotype conceptual model (three or more patient attributes of wasting, exhaustion, low activity, slowness, and weakness) is associated with increased morbidity and mortality in geriatric populations. OBJECTIVES Our objective was to describe the risks associated with frailty in patients with chronic obstructive pulmonary disease. METHODS Data from the National Emphysema Treatment Trial (NETT) were retrospectively analyzed. The frailty phenotype conceptual model was operationalized as three or more frailty parameters (a body mass index decrease of ≥5% over 12 months, self-reported exhaustion, low 6-minute walk distance, or physical activity or respiratory muscle strength in the lowest quartile). Frail participants were compared with participants with two or fewer frailty parameters. Participants were followed starting 12 months after NETT randomization (to minimize surgical effect) for 24 months. Univariate, multivariate, Kaplan-Meier, and Cox proportional hazard analyses were performed, adjusting for treatment arm, age, modified Medical Research Council dyspnea scale, sex, and baseline forced expiratory volume in 1 second (FEV1). Multiple imputation was used for missing values. RESULTS The participants (N = 902) were predominantly white (94.5%) males (59.5%), with a median age of 67 years (interquartile range, 63-70 yr) and a median FEV1% predicted of 26 (interquartile range, 20-33). Six percent of the participants (95% confidence interval [CI], 4.5 to 7.6) were frail. The incidence rate of frailty was 6.4 per 100 person-years. Frail participants reported significantly worse disease-specific and overall quality of life by St. George's Respiratory Questionnaire total score (mean difference of 11.6; 95% CI, 7.6 to 15.6; P < 0.001), mental composite on Medical Outcomes Survey Short Form-36 (mean difference -6.8; 95% CI, -10.0 to -3.6; P < 0.001), and physical composite scores on Medical Outcomes Survey Short Form-36 (mean difference -16.7; 95% CI, -21.3 to -12.1; P = 0.001). Frail participants had an increased rate of hospitalization (adjusted hazard ratio, 1.6; 95% CI, 1.1 to 2.5; P = 0.02) and an adjusted increase in hospital use of 8.0 days (95% CI, 4.4 to 11.6; P < 0.001) compared with nonfrail participants. Frail participants had a higher mortality rate (adjusted hazard ratio, 1.4; 95% CI, 0.97 to 2.0; P = 0.07). CONCLUSIONS Among adults with chronic obstructive pulmonary disease, our measure of frailty (modified from the Fried frailty phenotype) was associated with incident and longer-duration hospitalization, and with poor quality of life.
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Cogswell R, Trachtenberg B, Murray T, Schultz J, Teigen LEVI, Allen T, Araujo-Gutierrez R, John R, Martin CM, Estep J. A Novel Model Incorporating Pectoralis Muscle Measures to Predict Mortality After Ventricular Assist Device Implantation. J Card Fail 2020; 26:308-315. [DOI: 10.1016/j.cardfail.2019.11.021] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2019] [Revised: 10/29/2019] [Accepted: 11/19/2019] [Indexed: 01/14/2023]
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50
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Abstract
Background
A barrier to routine preoperative frailty assessment is the large number of frailty instruments described. Previous systematic reviews estimate the association of frailty with outcomes, but none have evaluated outcomes at the individual instrument level or specific to clinical assessment of frailty, which must combine accuracy with feasibility to support clinical practice.
Methods
The authors conducted a preregistered systematic review (CRD42019107551) of studies prospectively applying a frailty instrument in a clinical setting before surgery. Medline, Excerpta Medica Database, Cochrane Library and the Comprehensive Index to Nursing and Allied Health Literature, and Cochrane databases were searched using a peer-reviewed strategy. All stages of the review were completed in duplicate. The primary outcome was mortality and secondary outcomes reflected routinely collected and patient-centered measures; feasibility measures were also collected. Effect estimates were pooled using random-effects models or narratively synthesized. Risk of bias was assessed.
Results
Seventy studies were included; 45 contributed to meta-analyses. Frailty was defined using 35 different instruments; five were meta-analyzed, with the Fried Phenotype having the largest number of studies. Most strongly associated with: mortality and nonfavorable discharge was the Clinical Frailty Scale (odds ratio, 4.89; 95% CI, 1.83 to 13.05 and odds ratio, 6.31; 95% CI, 4.00 to 9.94, respectively); complications was associated with the Edmonton Frail Scale (odds ratio, 2.93; 95% CI, 1.52 to 5.65); and delirium was associated with the Frailty Phenotype (odds ratio, 3.79; 95% CI, 1.75 to 8.22). The Clinical Frailty Scale had the highest reported measures of feasibility.
Conclusions
Clinicians should consider accuracy and feasibility when choosing a frailty instrument. Strong evidence in both domains support the Clinical Frailty Scale, while the Fried Phenotype may require a trade-off of accuracy with lower feasibility.
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