Validity and Utility of the Questionnaire-based FRAIL Scale in Older Patients with Heart Failure: Findings from the FRAGILE-HF

Association Between Amount of Physical Activity and Clinical Outcomes After Treatment for Cardiovascular Disease in Cancer Survivors

Background

The present study aimed to investigate the association between physical activity before the incidence of cardiovascular disease (CVD) and clinical outcomes in cancer survivors.

Methods and Results

We analyzed 904 cancer survivors (median age [interquartile range] 75 [68-80] years; 297 [32.9%] patients were female) who required hospitalization for treatment of CVD. The amount of physical activity 1 month before the admission was assessed using the 3-question (3Q) assessment tool, and categorized as minimal, low, adequate, and high according to physical activity level. The primary outcome was the composite events of all-cause death and/or rehospitalization for CVD up to 1 year after discharge. The total amount of physical activity was identified in 544 (60.2%) patients in the minimal group, 95 (10.5%) in the low group, 253 (28.0%) in the adequate group, and 12 (1.3%) in the high group. A total of 686 (75.9%) patients completed follow up, with 252 (27.9%) composite events occurring. Even after adjustment for various confounders, higher physical activity was significantly associated with a lower composite event rate (adjusted hazard ratio [95% confidence interval] 0.859 [0.833-0.900]).

Conclusions

High physical activity in cancer survivors was associated with a lower composite event rate after treatment for CVD. Assessment of prehospital physical activity using the 3Q score may be useful in their risk stratification.

Comparison of Physical Frailty Assessments in Heart Failure With Preserved Ejection Fraction

Background

Frailty is a known determinant of poor clinical outcomes in heart failure with preserved ejection fraction (HFpEF). However, prevalence estimates and effect sizes vary in part due to multiple tools available to measure frailty.

Objectives

This study aimed to compare the prevalence and prognostic value of six commonly used frailty assessments in adults with HFpEF.

Methods

We examined 203 outpatients with HFpEF seen at Weill Cornell Medicine from June 2018 to August 2022. The following frailty scales were compared: the Clinical Frailty Scale (CFS), the Fatigue, Resistance, Ambulation, Illnesses, and Loss of Weight scale (FRAIL) scale, the 5-m gait speed test, the 5 timed sit-to-stand test, hypoalbuminemia, and the modified body mass index score. The primary endpoint was a 1-year composite of all-cause mortality and hospitalization. Cox proportional hazard models were used to examine the association between frailty and the primary endpoint, adjusting for race and the MAGGIC (Meta-Analysis Global Group in Chronic) heart failure prognostic risk score.

Results

The median age was 76.7 years (IQR: 69.7-83.9 years). The prevalence of frailty ranged from 21.2% (hypoalbuminemia) to 77.8% (5 timed sit-to-stand) and increased with advancing HFpEF severity. Of the 6 frailty assessments, the CFS (HR: 2.83; 95% CI: 1.61-4.98, P < 0.001), FRAIL scale (HR: 1.96; 95% CI: 1.25-3.07, P = 0.004), and 5-m gait speed test (HR: 2.80; 95% CI: 1.50-5.25, P = 0.001) were associated with adverse outcomes in the multivariate analysis.

Conclusions

Frailty assessments yield a wide range of prevalence estimates and vary in their associations with clinical outcomes. The CFS, FRAIL scale, and the 5-m gait speed tests demonstrated associations with adverse outcomes and may thus be reasonable tools for routine use in patients with HFpEF.

A systematic review and meta-analysis of frailty in patients with heart failure

OBJECTIVE

To systematically evaluate the effect of frailty on the prognosis of patients with heart failure.

METHODS

Computer searches were conducted on PubMed, Embase, The Cochrane Library, Web of Science, CNKI, Wanfang Data Knowledge Service platform, Weipu full-text database of Chinese scientific and technological journals, and Chinese biomedical literature database from August 12, 2022. After literature screening was completed by two researchers, the data extraction (such as study type, sample size, age of included patients, New York Heart Association (NYHA) Functional Classification, frailty assessment tool, frailty positive rate, outcome indicators, etc.) was performed and the risk of bias in the included studies was assessed. Meta-analysis was performed using Revman 5.4 and Stata 14.0 software.

RESULTS

A total of 32 studies were included, including 406,269 patients with heart failure. All included studies were rated high overall quality. The results of meta-analysis showed: Frailty increases the risk of all-cause death in patients with heart failure (hazard ratio [HR] = 1.73, 95% confidence interval [CI]: 1.50 - 2.00, p < 0.001), unplanned readmission (HR = 1.96, 95% CI: 1.21 - 3.17, p = 0.006), and joint endpoint risk (HR = 1.66, 95% CI: 1.48 - 1.86, p < 0.001).

CONCLUSION

Current evidence suggests that frailty increases the risk of all-cause death, unplanned readmission, and joint endpoints in patients with heart failure.

Psychometric Properties of the FRAIL Scale for Frailty Screening: A Scoping Review

OBJECTIVES

The aim of this study was to identify and map the available psychometric evidence of the FRAIL scale to screen frailty among older adults.

DESIGN

Scoping review of published articles on 9 databases (PubMed, Scopus, Web of Science, CINAHL, Cochrane, Embase, PsycINFO, VHL Regional Portal, and Epistemonikos) and 8 gray literature sources.

SETTING AND PARTICIPANTS

Studies in adults or older adults, in both inpatient and outpatient settings (without context restrictions).

METHODS

Cross-cultural adaptations, validity and reliability evidence studies, whose main objective was to develop and/or validate and/or culturally adapt the FRAIL Scale to assess frailty in adults or older adults, published since 2007 were included in this scoping review. The databases were searched between February and March 2023.The JBI methodology for scoping reviews was used to guide the process. The protocol of this study was registered on the Open Science Framework platform.

RESULTS

Of the 1031 records found during the search, 40 articles that met the established criteria for analysis were included. Nearly 1 in 10 countries worldwide (11.9%) have psychometric evidence regarding this scale. Ten studies were identified with the goal of cross-cultural adaptation and/or validation in a different cultural context for the first time. Twenty-one of 40 studies used Morley 2012 operationalization of FRAIL Scale criteria. Thirty-nine studies provided evidence of associations with other variables. The rest of the evidence for content, internal structure, response processes, and reliability was only evaluated in cross-cultural adaptation studies, with limitations.

CONCLUSIONS AND IMPLICATIONS

In conclusion, there is some evidence of validity for FRAIL Scale; nevertheless, studies are needed to adapt the scale to new cultures, using rigorous Cross-Cultural Adaptation processes, and to provide new evidence of validity and reliability, to strengthen and consolidate the body of knowledge for its application to various patient groups and context.

Screening for frailty and its association with activities of daily living, cognitive impairment, and falls among community-dwelling older adults in China

OBJECTIVES

Frailty is a prevalent geriatric condition that significantly impacts the health of older adults. This study aimed to examine the prevalence of frailty among older Chinese adults aged ≥ 65 years and to assess its association with adverse geriatric outcomes.

METHOD

This study included 20,724 older adults aged ≥ 65 years in Jiangsu Province, China, utilizing a random, stratified, multistage cluster sampling approach. Frailty was assessed using the 5-item FRAIL scale. Geriatric outcomes, such as independence in activities of daily living (ADL), cognitive impairment, and frequent fall events (occurring four or more times in the preceding year), were evaluated. Logistic regression models were employed to evaluate the association between frailty and geriatric outcomes, with results presented as odds ratios (ORs) and 95% confidence intervals (CIs).

RESULTS

The mean age of the participants was 73.4 ± 6.4 years. The standardized prevalence of prefrailty and frailty was 35.2% and 10.3%, respectively. Individuals identified as prefrail or frail tended to live in rural areas, have lower educational levels, be widowed, have lower incomes, and engage in less physical activity. Prefrailty and frailty were associated with an increased risk of limitations in BADL (OR: 9.62, 95% CI: 7.43-12.46; and OR: 29.25, 95% CI: 22.42-38.17, respectively) and IADL (OR: 2.54, 95% CI 2.35-2.74; and OR: 5.19, 95% CI 4.66-5.78, respectively), positive cognitive impairment screening (OR: 1.23, 95% CI: 1.16-1.31; and OR: 1.72, 95% CI: 1.56-1.91, respectively), and frequent falls (occurring four or more times in the preceding year) (OR: 3.38, 95% CI: 2.50-4.56; and OR: 8.37, 95% CI: 6.01-11.65). The association between frailty and both limitations in BADL and falls was notably more pronounced among the younger age groups (p for interaction < 0.001).

CONCLUSIONS

According to the 5-item FRAIL scale, frailty was associated with limitations in BADLs and IADLs, positive cognitive impairment screening, and recent falls among older adults living in the community. Screening for frailty in younger age groups has the potential to prevent declines in physical function and falls.

Association between walking speed early after admission and all-cause death and/or re-admission in patients with acute decompensated heart failure

AIMS

Patients with heart failure (HF) frequently experience decreased physical function, including walking speed. Slower walking speed is associated with poorer prognosis. However, most of these reports focused on patients with stable HF, and the relationship between walking speed in acute phase and clinical outcomes is unclear. Therefore, we aimed to investigate the associations between walking speed early after admission and clinical events in patients with acute decompensated HF (ADHF).

METHODS AND RESULTS

We reviewed consecutive 1391 patients admitted due to ADHF. We measured walking speed the first time to walk on the ward more than 10 m after admission, and the speed within 4 days after admission was included in this study. The primary outcome was combined events (all-cause death and/or re-admission due to HF). The follow-up period was up to 1 year from the discharge. The study population had a median age of 74 years [interquartile range (IQR): 65-80 years], and 35.9% of patients were females. The median walking speed was 0.70 m/s (IQR: 0.54-0.88 m/s). Combined events occurred in 429 (30.8%) patients. Faster walking speed was independently associated with lower rate of combined events (adjusted hazard ratio per 0.1 m/s increasing: 0.951, 95% confidence interval: 0.912-0.992).

CONCLUSION

Faster walking speed within 4 days after admission was associated with favourable clinical outcomes in patients with ADHF. The results suggest that measuring walking speed in acute phase is useful for earlier risk stratification.

Prognostic impact of MitraScore in elderly Asian patients with heart failure: sub-analysis of FRAGILE-HF

AIMS

MitraScore is a novel, simple, and manually calculatable risk score developed as a prognostic model for patients undergoing transcatheter edge-to-edge repair (TEER) for mitral regurgitation. As its components are considered prognostic in heart failure (HF), we aimed to investigate the usefulness of the MitraScore in HF patients.

METHODS AND RESULTS

We calculated MitraScore for 1100 elderly patients (>65 years old) hospitalized for HF in the prospective multicentre FRAGILE-HF study and compared its prognostic ability with other simple risk scores. The primary endpoint was all-cause deaths, and the secondary endpoints were the composite of all-cause deaths and HF rehospitalization and cardiovascular deaths. Overall, the mean age of 1100 patients was 80 ± 8 years, and 58% were men. The mean MitraScore was 3.2 ± 1.4, with a median of 3 (interquartile range: 2-4). A total of 326 (29.6%), 571 (51.9%), and 203 (18.5%) patients were classified into low-, moderate-, and high-risk groups based on the MitraScore, respectively. During a follow-up of 2 years, 226 all-cause deaths, 478 composite endpoints, and 183 cardiovascular deaths were observed. MitraScore successfully stratified patients for all endpoints in the Kaplan-Meier analysis (P < 0.001 for all). In multivariate analyses, MitraScore was significantly associated with all endpoints after covariate adjustments [adjusted hazard ratio (HR) (95% confidence interval): 1.22 (1.10-1.36), P < 0.001 for all-cause deaths; adjusted HR 1.17 (1.09-1.26), P < 0.001 for combined endpoints; and adjusted HR 1.24 (1.10-1.39), P < 0.001 for cardiovascular deaths]. The Hosmer-Lemeshow plot showed good calibration for all endpoints. The net reclassification improvement (NRI) analyses revealed that the MitraScore performed significantly better than other manually calculatable risk scores of HF: the GWTG-HF risk score, the BIOSTAT compact model, the AHEAD score, the AHEAD-U score, and the HANBAH score for all-cause and cardiovascular deaths, with respective continuous NRIs of 0.20, 0.22, 0.39, 0.39, and 0.29 for all-cause mortality (all P-values < 0.01) and 0.20, 0.22, 0.42, 0.40, and 0.29 for cardiovascular mortality (all P-values < 0.02).

CONCLUSIONS

MitraScore developed for patients undergoing TEER also showed strong discriminative power in HF patients. MitraScore was superior to other manually calculable simple risk scores and might be a good choice for risk assessment in clinical practice for patients receiving TEER and those with HF.

Association between natriuretic peptides and C-reactive protein with frailty in heart failure: a systematic review and meta-analysis

BACKGROUND

Heart failure (HF) and frailty are accompanied by a bidirectional relationship, sharing common risk factors including elevated levels of natriuretic peptides and inflammation. The aim of this study was to compare biomarkers associated with poor clinical outcomes, that is, plasma brain natriuretic peptide (BNP), N-terminal-pro B-type natriuretic peptide (NT-proBNP), and C-reactive protein (CRP) in patients with HF and frailty vs. patients with HF without frailty.

METHODS

From inception until July 2023, PubMed, Scopus, Web of Science, and Cochrane Library a systematic literature search was conducted. To evaluate whether frailty is linked with greater levels of BNP, NT-proBNP, and CRP, a meta-analysis using a random-effects model was used to calculate the pooled effects (CRD42023446607).

RESULTS

Fifty-three studies were included in this systematic review and meta-analysis. Patients with HF and frailty displayed significantly higher levels of BNP (k = 11; SMD: 0.53, 95%CI 0.30-0.76, I2 = 86%, P < 0.01), NT-proBNP (k = 23; SMD: 0.33, 95%CI 0.25-0.40, I2 = 72%, P < 0.01), and CRP (k = 8; SMD: 0.30, 95%CI 0.12-0.48, I2 = 62%, P < 0.01) vs. patients with HF without frailty. Using meta-regression, body mass index (BMI) and age were deemed potential moderators of these findings.

CONCLUSIONS

Frailty in HF is linked to increased concentrations of BNP, NT-proBNP, and CRP, which have been epidemiologically associated with adverse outcomes. The increased risk of NYHA III/IV classification further emphasizes the clinical impact of frailty in this population.

The measurement properties and feasibility of FRAIL scale in older adults: A systematic review and meta-analysis

Frailty is a prevalent condition amongst older adults, significantly affecting their quality of life. The FRAIL tool has been purposefully designed for clinical application by assisting healthcare professionals in identifying and managing frailty-related issues in older adults, making it a preferred choice for assessing frailty across diverse older populations. This review aimed to synthesize the measurement properties and feasibility of FRAIL. Guided by COSMIN guidelines, seven databases were searched from inception to 31 Mar 2023. The measurement properties were extracted for quality appraisal of the populations in the studied samples. Where possible, random-effects meta-analysis and meta-regression were used for quantitative synthesis. Eighteen articles containing 273 tests were drawn from 14 different populations. We found that populations testing for criterion validity had high-quality ratings, while construct validity ratings varied based on health status and geographical region. Test-retest reliability had sufficient quality ratings, while scale agreement had sufficient ratings in only four out of 14 populations tested. Responsiveness ratings were insufficient in seven out of eight populations, with inconsistent ratings in one population. Our analysis of missing data across three articles showed a 16.3% rate, indicating good feasibility of the FRAIL. FRAIL is a feasible tool for assessing frailty of older adults in community settings, with good criterion validity and test-retest reliability. However, more research is needed on construct validity and responsiveness.

Association of affected and non-affected side ability with postoperative outcomes in patients undergoing total hip arthroplasty

BACKGROUND

Although several reports have examined the association between preoperative function and postoperative outcomes in patients undergoing total hip arthroplasty (THA), it is unclear whether the ability of the affected or non-affected side particularly impacts on outcomes. We aimed to investigate the association between affected and non-affected side ability and walking independence.

METHODS

We prospectively enrolled 721 consecutive patients who underwent THA. Preoperatively, quadriceps isometric strength (QIS) and one-leg standing time (OLST) were measured. The endpoints were walking independence within 3, 5, 7, 10, and 14 days postoperatively. The associations between preoperative abilities and outcomes were examined using multivariate Cox hazard model, and the area under the curves (AUCs) for outcomes were compared.

RESULTS

We analysed 540 patients after excluding patients who met the exclusion criteria. Both affected and non-affected QIS predicted walking independence within 3 (p = 0.006 and 0.001, respectively), 5, 7, 10, and 14 (both p < 0.001) days postoperatively. For OLST, only the affected side did not predict walking independence within 3 days postoperatively (p = 0.154 and 0.012, respectively), and both sides did at days 5 (p = 0.019 and <0.001, respectively), 7, 10, and 14 (both p < 0.001). The AUCs of the non-affected side ability for walking independence were significantly greater than those of the affected side on postoperative days 3 (0.66 vs. 0.73; p = 0.021) and 5 (0.67 vs. 0.71; p = 0.040), with no significant difference after day 7.

CONCLUSIONS

Both sides abilities were associated with walking independence after THA, but non-affected side was found to be particularly crucial for early walking independence.

Sodium-Glucose Cotransporter 2 Inhibitors in Frail Patients with Heart Failure: Clinical Experience of a Heart Failure Unit

OBJECTIVE

The objective of this study was to determine the difference in tolerance for sodium glucose cotransporter 2 inhibitors between patients with heart failure classified as frail according to the FRAIL questionnaire, compared to those with heart failure without frailty.

METHODS

A prospective cohort study was performed between 2021 and 2022 that included patients with heart failure at a heart failure unit in Bogotá who were being treated with a sodium glucose cotransporter 2 inhibitor. Clinical and laboratory data were collected during an initial visit and 12-48 weeks after that. The FRAIL questionnaire was applied to all participants through a phone call or during the follow-up visit. The primary outcome was the adverse effect rate and as a secondary outcome we compared the estimated glomerular filtration rate change between frail and non-frail patients.

RESULTS

One hundred and twelve patients were included in the final analysis. Frail patients had a more than twice increased risk of having adverse effects (95% confidence interval 1.5-3.9). Age was also a risk factor for the appearance of these.  The estimated glomerular filtration rate decrease was inversely correlated with the age, left ventricular ejection fraction, and renal function before the use of sodium glucose cotransporter 2 inhibitors.

CONCLUSIONS

When prescribing in heart failure, it is important to remember that frail patients are more likely to have adverse effects with the use of sodium glucose cotransporter 2 inhibitors, of which the most common are those related to osmotic diuresis. Nonetheless, these do not appear to increase the risk of discontinuation or abandonment of therapy in this population.

Utility of the Fatigue, Resistance, Ambulation, Illness, and Loss of weight Scale in Older Patients with Cardiovascular Disease

OBJECTIVES

To compare the Fried criteria for frailty diagnosis with the Frailty Screening Index (FSI) and the fatigue, resistance, ambulation, illness, and loss of weight (FRAIL) scale in older patients with cardiovascular disease (CVD).

DESIGN

We conducted a retrospective 1-year follow-up cohort study of adult inpatients who participated in a cardiac rehabilitation program between June 2016 and September 2018.

SETTING AND PARTICIPANTS

We included 1472 Japanese patients age 65 years and older with CVD. After excluding 765 patients with incomplete frailty measurements, 707 patients were included in the analysis.

METHODS

Frailty and physical function were measured before hospital discharge according to each of the 3 definitions. Outcomes were all-cause mortality and physical dysfunction.

RESULTS

The prevalence of frailty according to the Fried criteria, the FRAIL scale, and the FSI was 213 (30.1%), 181 (25.6%), and 186 (26.3%), respectively. The FSI and the FRAIL scale showed moderate agreement with the Fried criteria [vs FSI: K = 0.52, 95% confidence interval (CI): 0.45-0.59; vs FRAIL scale: K = 0.45, 95% CI: 0.37-0.52; all P < .001]. We found a significant correlation between all-cause mortality and frailty assessed by all of the definitions, even after multivariate adjustment [FSI: hazard ratio (HR): 2.43, 95% CI: 1.30-4.58, P = .006; FRAIL scale: HR: 2.32, 95% CI: 1.21-4.45, P = .011; Fried criteria: HR: 1.99, 95% CI: 1.04-3.82, P = .038). However, the prediction accuracy of the FRAIL scale was higher than that of the FSI and comparable to that of the Fried criteria for physical dysfunction.

CONCLUSIONS AND IMPLICATIONS

The FSI and the FRAIL scale showed moderate agreement with the Fried criteria regarding frailty diagnostic performance and had comparable prognostic value. However, only the FRAIL scale was as accurate as the Fried criteria in screening for physical dysfunction.

Clinical Perspectives on Cardiac Rehabilitation After Heart Failure in Elderly Patients with Frailty: A Narrative Review

The purpose of this narrative review is to examine rehabilitation modalities for patients with heart failure and Frailty who require comprehensive intervention. Ischemic heart disease is the leading cause of death worldwide, accounting for 16% of global mortality. Due to population growing and aging, the total number of heart failure patients continues to rise, a condition known as the heart failure pandemic. Furthermore, frailty has been associated with an increased risk for heart failure and increased morbidity and mortality. The 2021 update of the 2017 ACC expert consensus decision pathway for optimization of HF treatment has become more concerning, citing frailty as one of the 10 most important issues associated with heart failure with reduced ejection fraction (HFrEF). Frailty and heart failure share common pathological mechanisms and are associated with poor clinical outcomes. Most studies of frailty in patients with heart failure primarily focus on physical frailty, and associations between psycho-psychological and social factors such as cognitive dysfunction and social isolation have also been reported. These results suggest that a more comprehensive assessment of frailty is important to determine the risk in patients with heart failure. Therefore, mechanisms of the three domains, including not only physical frailty but also cognitive, psychological, spiritual, and social aspects, should be understood. In addition to interventions in these three domains, nutritional and pharmacological interventions are also important and require tailor-made interventions for the widely varied conditions associated with heart failure and frailty. Although several studies have shown a relationship between frailty and prognosis in patients with heart failure, interventions to improve the prognosis have not yet been established. Further information is needed on frailty intervention by a multidisciplinary team to improve the prognosis.

Association of frailty and functional recovery in an Acute Care for Elders unit: a prospective observational study

Background

Evidence on the effects of Acute Care for Elders (ACE) units in frail older adults remains limited. Therefore, we aimed to evaluate the effects of the ACE unit on functional outcomes in frail older adults.

Methods

In this prospective observational study, we enrolled 114 consecutive patients aged 65 years and older admitted to the ACE unit for acute medical conditions between October 2019 and September 2020. The FRAIL scale (5-question assessment of fatigue, resistance, aerobic capacity, illnesses, and loss of weight) was used to classify the patients into three groups: robust (score = 0, n = 28), prefrail (score = 1–2, n = 57), and frail (score = 3–5, n = 29). The primary outcome was the activities of daily living (ADL) measured by the Barthel Index at admission and before discharge. Paired sample t-test was employed to determine the difference in ADL. Multiple linear regression analysis, with adjustment for covariates, was conducted to examine the association between frailty status and change in ADL.

Results

Among 114 patients enrolled (mean age, 79.8 ± 8.1 years; mean length of stay, 6.4 ± 5.6 days), 77 (67.5%) were female. ADL at admission (60.3 ± 31.9) and before discharge (83.7 ± 21.6) were significantly different (P < 0.001). After covariates adjustment, a significant association between frailty status and change in ADL was found (prefrail vs. robust: β = 9.0, 95% confidence interval [CI] 0.3–17.6, P = 0.04; frail vs. robust: β = 13.4, 95% CI 2.7–24.0, P = 0.01).

Conclusions

Older adults with frailty experienced functional improvement after admission to the ACE unit. Prefrail and frail groups were associated with a more significant change in ADL between admission and discharge compared to the robust group.

Prognostic value of postural hypotension in hospitalized patients with heart failure

Although postural hypotension (PH) is reportedly associated with mortality in the general population, the prognostic value for heart failure is unclear. This was a post-hoc analysis of FRAGILE-HF, a prospective multicenter observational study focusing on frailty in elderly patients with heart failure. Overall, 730 patients aged ≥ 65 years who were hospitalized with heart failure were enrolled. PH was defined by evaluating seated PH, and was defined as a fall of ≥ 20 mmHg in systolic and/or ≥ 10 mmHg in diastolic blood pressure within 3 min after transition from a supine to sitting position. The study endpoints were all-cause death and heart failure readmission at 1 year. Predictive variables for the presence of PH were also evaluated. PH was observed in 160 patients (21.9%). Patients with PH were more likely than those without PH to be male with a New York Heart Association classification of III/IV. Logistic regression analysis showed that male sex, severe heart failure symptoms, and lack of administration of angiotensin-converting enzyme inhibitors were independently associated with PH. PH was not associated with 1-year mortality, but was associated with a lower incidence of readmission after discharge after adjustment for other covariates. In conclusion, PH was associated with reduced risk of heart failure readmission but not with 1-year mortality in older patients with heart failure.

Sex differences in the prevalence and prognostic impact of physical frailty and sarcopenia among older patients with heart failure

BACKGROUND AND AIMS

Frailty and sarcopenia are common and confer poor prognosis in elderly patients with heart failure; however, gender differences in its prevalence or prognostic impact remain unclear.

METHODS AND RESULTS

We included 1332 patients aged ≥65 years, who were hospitalized for heart failure. Frailty and sarcopenia were defined using the Fried phenotype model and Asian Working Group for Sarcopenia criteria, respectively. Gender differences in frailty and sarcopenia, and interactions between sex and prognostic impact of frailty/sarcopenia on 1-year mortality were evaluated. Overall, 53.9% men and 61.0% women and 23.7% men and 14.0% women had frailty and sarcopenia, respectively. Although sarcopenia was more prevalent in men, no gender differences existed in frailty after adjusting for age. On Kaplan-Meier analysis, frailty and sarcopenia were significantly associated with 1-year mortality in both sexes. On Cox proportional hazard analysis, frailty was associated with 1-year mortality only in men, after adjusting for confounding factors (hazard ratio [HR], 1.94; 95% confidence interval [CI], 1.19-3.16; P = 0.008 for men; HR, 1.63; 95% CI, 0.84-3.13; P = 0.147 for women); sarcopenia was an independent prognostic factor in both sexes (HR, 1.93; 95% CI, 1.13-3.31; P = 0.017 for men; HR, 3.18; 95% CI, 1.59-5.64; P = 0.001 for women). There were no interactions between sex and prognostic impact of frailty/sarcopenia (P = 0.806 for frailty; P = 0.254 for sarcopenia).

CONCLUSIONS

Frailty and sarcopenia negatively affect older patients with heart failure from both sexes.

CLINICAL TRIALS

This study was registered at the University Hospital Information Network (UMIN-CTR, unique identifier: UMIN000023929) before the first patient was enrolled.

Inaccurate recognition of own comorbidities is associated with poor prognosis in elderly patients with heart failure

Aims

A patient's understanding of his or her own comorbidities is part of the recommended patient education for those with heart failure. The accuracy of patients' understanding of their comorbidities and its prognostic impact have not been reported.

Methods and results

Patients hospitalized for heart failure (n = 1234) aged ≥65 years (mean age: 80.1 ± 7.7 years; 531 females) completed a questionnaire regarding their diagnoses of diabetes, malignancy, stroke, hypertension, chronic obstructive pulmonary disease (COPD), and coronary artery disease (CAD). The patients were categorized into three groups based on the number of agreements between self‐reported comorbidities and provider‐reported comorbidities: low (1–2, n = 19); fair (3–4, n = 376); and high (5–6, n = 839) agreement groups. The primary outcome was a composite of all‐cause mortality or heart failure rehospitalization at 1 year. The low agreement group had more comorbidities and a higher prevalence of a history of heart failure. The agreement was good for diabetes (κ = 0.73), moderate for malignancy (κ = 0.56) and stroke (κ = 0.50), and poor‐to‐fair for hypertension (κ = 0.33), COPD (κ = 0.25), and CAD (κ = 0.30). The fair and low agreement groups had poorer outcomes than the good agreement group [fair agreement group: hazard ratio (HR): 1.25; 95% confidence interval (CI): 1.01–1.56; P = 0.041; low agreement group: HR: 2.74: 95% CI: 1.40–5.35; P = 0.003].

Conclusions

The ability to recognize their own comorbidities among older patients with heart failure was low. Patients with less accurate recognition of their comorbidities may be at higher risk for a composite of all‐cause mortality or heart failure rehospitalization.

Aspartate aminotransferase to alanine aminotransferase ratio is associated with frailty and mortality in older patients with heart failure

Frailty is a common comorbidity associated with adverse events in patients with heart failure, and early recognition is key to improving its management. We hypothesized that the AST to ALT ratio (AAR) could be a marker of frailty in patients with heart failure. Data from the FRAGILE-HF study were analyzed. A total of 1327 patients aged ≥ 65 years hospitalized with heart failure were categorized into three groups based on their AAR at discharge: low AAR (AAR < 1.16, n = 434); middle AAR (1.16 ≤ AAR < 1.70, n = 487); high AAR (AAR ≥ 1.70, n = 406). The primary endpoint was one-year mortality. The association between AAR and physical function was also assessed. High AAR was associated with lower short physical performance battery and shorter 6-min walk distance, and these associations were independent of age and sex. Logistic regression analysis revealed that high AAR was an independent marker of physical frailty after adjustment for age, sex and body mass index. During follow-up, all-cause death occurred in 161 patients. After adjusting for confounding factors, high AAR was associated with all-cause death (low AAR vs. high AAR, hazard ratio: 1.57, 95% confidence interval, 1.02–2.42; P = 0.040). In conclusion, AAR is a marker of frailty and prognostic for all-cause mortality in older patients with heart failure.