Frailty and heart failure: State‐of‐the‐art review

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.

Association of Ratio of eGFR by Cystatin C and Creatinine with Mortality in Heart Failure

“…Heart failure patients with sarcopenia and frailty are known to have a higher mortality. 10 Measures of frailty can be cumbersome to perform in the clinical setting. Similarly, measures of sarcopenia typically require additional imaging, incurring extra costs for patients in terms of both time and finances.…”

Frailty and Cardiovascular Disease: A Bidirectional Association

“…The impact of frailty on patient outcomes was investigated across various cardiovascular conditions. Among patients with heart failure (HF), frailty is more common than in the general papulation, with a reported prevalence of 21-80% [7][8][9]. Prevalence is higher among women, as well as in patients with HF with preserved ejection fraction, relative to those with reduced ejection fraction [8].…”

“…Among patients with heart failure (HF), frailty is more common than in the general papulation, with a reported prevalence of 21-80% [7][8][9]. Prevalence is higher among women, as well as in patients with HF with preserved ejection fraction, relative to those with reduced ejection fraction [8]. Frailty constitutes an independent risk factor for mortality and hospitalizations related to HF, and it was demonstrated that adding frailty assessment to HF risk scores improves the discrimination ability for future death and HF hospitalizations [7].…”

“…Frailty constitutes an independent risk factor for mortality and hospitalizations related to HF, and it was demonstrated that adding frailty assessment to HF risk scores improves the discrimination ability for future death and HF hospitalizations [7]. Interventions and specific treatments that target HF were shown also to reduce or even reverse frailty [3,4,7,8]. It was suggested that frail individuals with HF are less likely to receive optimal guideline-directed medical therapy.…”

“…It was suggested that frail individuals with HF are less likely to receive optimal guideline-directed medical therapy. For instance, only 10.9% of frail patients that were otherwise eligible for angiotensin receptor-neprilysin inhibitor were prescribed with this drug [8]. It was further shown that even when receiving optimal guideline-directed medical therapy, frail patients are less likely to achieve the optimal drug doses due to their vulnerability to adverse effects [4].…”