Modified frailty as a novel factor in predicting the response to cardiac resynchronization in the elderly population

Association between frailty and adverse outcomes after cardiac resynchronization therapy: a systematic review and meta-analysis

AIM

To synthesize evidence, using data from published studies, on the association of frailty with the outcomes after cardiac resynchronization therapy (CRT).

METHODS

The systematic search of PubMed, Web of Science, Scopus, and Embase databases was done to identify observational studies (cohort/case-control/cross-sectional) that used an objective method for frailty assessment and had presented adjusted effect sizes. STATA version 15.0 was used to conduct analysis, which was based on random effects model.

RESULTS

Fifteen studies were included. Frailty was found to be associated with an increased risk of in-hospital mortality (odds ratio (OR) 6.96, 95% confidence interval (CI) 5.48, 8.85). The effect of frailty on the response to CRT was not statistically significant (OR 0.55, 95% CI 0.19, 1.59). The pooled effect size indicated that frailty was associated with somewhat bigger but not statistically significant increase in the risk of complications (OR 1.70, 95% CI 0.93, 3.12). The risks of mortality and decompensated heart failure on long-term follow up were higher in frail patients (Hazard ratio (HR) 1.75, 95% CI 1.40, 2.17 and HR 3.03, 95% CI 1.33, 6.90, respectively) compared to patients without frailty. The risk of readmission was higher in frail patients, however, it did not achieve statistical significance (HR 2.63, 95% CI 0.89, 7.75).

CONCLUSION

Frail CRT patients could be at higher risks of mortality, decompensated heart failure, and may have potentially higher rates of complications. Integrating frailty assessment into pre-CRT evaluation and customizing interventions for frail patients might be an essential steps towards enhancing outcomes in this population.

Outcomes following cardiac resynchronisation therapy in older people

INTRODUCTION

Older patients may be less likely to receive cardiac resynchronisation therapy (CRT) for the management of heart failure. We aimed to describe the differences in clinical response, complications, and subsequent outcomes following CRT implantation compared to younger patients.

METHODS

We conducted a retrospective cohort study of unselected, consecutive patients implanted with CRT devices between March 2008 and July 2017. We recorded complications, symptomatic and echocardiographic response, hospitalisation for heart failure, and all-cause mortality comparing patients aged <70, 70-79 and ≥ 80 years.

RESULTS

Five hundred and seventy-four patients (median age 76 years [interquartile range 68-81], 73.3% male) received CRT. At baseline, patients aged ≥80 years had worse symptoms, were more likely to have co-morbidities, and less likely to be receiving comprehensive medical therapy, although left ventricular function was similar. Older patients were less likely to receive CRT-defibrillators compared to CRT-pacemakers. Complications were infrequent and not more common in older patients. Age was not a predictor of symptomatic or echocardiographic response to CRT (67.2%, 71.2% and 62.6% responders in patients aged <70, 70-79 and ≥ 80 years, respectively; P = 0.43), and time to first heart failure hospitalisation was similar across age groups (P = 0.28). Ten-year survival was lower for older patients (49.9%, 23.9% and 6.8% in patients aged <70, 70-79 and ≥ 80 years, respectively; P < 0.001).

CONCLUSIONS

The benefits of CRT on symptoms and left ventricular function were not different in older patients despite a greater burden of co-morbidities and less optimal medical therapy. These findings support the use of CRT in an ageing population.

Use of the Tilburg frailty indicator in longitudinal studies with older adults: A scoping review

AIM

To understand how researchers applied the Tilburg Frailty Indicator (TFI) to older adults. The use of the TFI was examined based on the Integral Conceptual Model of Frailty (ICMF).

DESIGN

A scoping review.

DATA SOURCES

A database search was conducted without a time limit in PubMed, CINAHL, Embase and the Cochrane library. A hand search was also conducted.

REVIEW METHODS

Research questions were developed based on the population-concept-context framework suggested by the Joanna Briggs Institute (2017). Studies were included if topics were related to the use of the TFI or ICMF and designs were longitudinal studies.

RESULTS

A total of 37 studies met the inclusion criteria. Studies were reviewed according to the tested pathways of the ICMF: determinants of frailty or adverse outcomes, adverse outcomes of frailty and comparison of predictive power between frailty measures.

CONCLUSION

The TFI is a useful tool to screen for frailty and predict health outcomes in older adults. Among the pathways of the ICMF, relationships between social factors and frailty were reported in several studies. Despite this relationship, social factors were considered as items to assess the social domain of frailty rather than determinants of frailty. The predictive power of the TFI was not superior to other frailty measures, but it had a high sensitivity.

IMPACT

This study demonstrates the usability of the TFI in older adults living in various conditions. Further studies are required to identify more effective ways to screen frailty using the TFI.

PATIENT OR PUBLIC CONTRIBUTION

No patient or public involvement in this study.

Predictors of Early Cardiac Implantable Electronic Device Lead Dislodgement in the Elderly

INTRODUCTION

One of the most frequent cardiac implantable electronic device (CIED) implantation complications is lead dislodgement, especially in the older adult population. Little evidence is available about the influence of frailty on the risk of lead dislodgment after CIED implantation procedures; thus, the evaluation of frailty could be relevant for the course and safety of the implantation procedure, especially among the elderly with cardiovascular diseases. This study aimed to assess the risks and predictors of early lead dislodgement in the elderly population.

METHODS

Between 2008 and 2021, 14,293 patients underwent implantations. In 400 elderly patients, lead dislodgement was confirmed, and frailty was retrospectively calculated.

RESULTS

The most frequent dislodgement according to the lead position was that of the atrial lead (133; 33.3%). In the logistic regression, frailty (OR: 1.8196, 95% CI:1.4991-2.2086; p < 0.0001) and age (OR: 1.0315, 95% CI:1.0005-1.0634; p < 0.0461) were independent predictors of early dislodgement. In the female group, frailty (OR: 2.1185, 95% CI: 1.5530-2.8899; p < 0.0001) was an independent predictor of early dislodgement. Similarly, in the male group, frailty (OR: 1.6321, 95% CI:1.2725-2.0934; p < 0.0001) was an independent predictor of early dislodgement.

CONCLUSION

Lead dislodgement often occurs in the elderly. Frailty in both men and women is a predictive factor of early lead dislodgment. Evaluating frailty may be an essential element of proper selection, especially in the elderly undergoing CIED procedures, and, consequently, it could help prevent further complications.

Frailty Syndrome in Older Adults with Cardiovascular Diseases-What Do We Know and What Requires Further Research?

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.

A Novel and Simple Exercise Test Parameter to Assess Responsiveness to Cardiac Resynchronization Therapy

This study assessed the value of heart rate recovery index (HRRI), a new parameter of an exercise test, as the predictor of response to cardiac resynchronization therapy (CRT). Methods: Consecutive patients receiving a CRT device were followed up after implantation and every 6 months. An effort test (ET) was quantified by minimum heart rate/maximum heart rate, as well as acceleration and deceleration times. HRRI was calculated as the ratio between acceleration and deceleration time (AT/DT) and compared to outcome. We used logistic regression to assess the predictive value of HRRI for responders and non-responders to CRT. The area under the curve (AUC) was computed to distinguish between positive and negative outcomes. Results: A total of 109 patients (74 men, mean age 63.3 ± 9.8 years) were analyzed; permanent long-term fusion CRT pacing was possible in 65 patients. Patients were assigned to two groups: responders and non-responders (98/11 patients). During a mean follow-up of 36 months, 545 ETs were performed. HRRI was significantly higher in responders versus non-responders (3.16 ± 2 vs. 1.4 ± 0.5, p < 0.001). The optimal cutoff value for HRRI as a predictor of CRT response was 1.51 (area under the receiver operating characteristic (ROC) curve = 0.844). Responders had significant left-ventricular (LV) reverse remodeling (LV end-diastolic volume = 240 ± 90 mL vs. 217 ± 89 mL, p < 0.001) and higher LV ejection fraction (26 ± 5.8% vs. 35 ± 8.7%, p < 0.001). Conclusions: HRRI computation during routine ET is useful for the evaluation of responsiveness to CRT.

Utility of the Modified Frailty Index to Predict Cardiac Resynchronization Therapy Outcomes and Response

The aim of the present study was to investigate the utility of the modified frailty index (mFI) to predict outcomes in patients who underwent cardiac resynchronization therapy (CRT) device implantation. A retrospective cohort study of patients undergoing CRT implantation or upgrade over a 5-year period was performed. The relation between the preprocedural 11-component mFI and clinical outcomes including 1-year mortality, periprocedural and 30-day adverse events, 30-day readmission, length of hospitalization after procedure, and response to CRT defined by changes in left ventricular ejection fraction and end-diastolic volume were studied. Of 283 patients studied, 134 (47.3%) were classified as frail (mFI ≥3). Frailty was associated with an increased risk of 1-year mortality (hazard ratio 5.87, p = 0.033 in multivariate analysis), and increased frequency of adverse events (p = 0.013), 30-day readmission (p = 0.0077), and postprocedural length of stay ≥3 days (p = 0.0005). Frail patients had significantly less echocardiographic response to CRT compared with nonfrail patients with change in left ventricular ejection fraction 6% versus 12% (p = 0.004) and change in left ventricular end-diastolic volume -19.9 versus -43.3 ml (p = 0.006). In conclusion, frailty as assessed by the mFI is associated with an increase in 1-year mortality, adverse events, 30-day readmission, length of stay, and poorer response to CRT after implantation.