The clinical, physical, cognitive and social aspects of frailty are widespread in heart failure patients and are significantly associated with poor outcomes, which warrants a holistic approach to management, say British researchers.

Dr. Shirley Sze, NIHR Leicester Biomedical Research Center, University of Leicester, and colleagues studied over 460 outpatients with heart failure and found that each of the frailty deficits was present in at least 18% of the patients and 55% had at least two deficits.

Each deficit was individually associated with an increased likelihood of all-cause mortality and a combined outcome of hospitalization and death, but the presence of multiple deficits increased the risk dramatically.

Patients with all four frailty deficits had an almost 16-fold increased overall mortality risk, while the risk of the combined outcome was more than 8-fold increased.

The results show that all four aspects of frailty are “very common” in outpatients with heart failure, said Dr. Sze and “are independently associated with a high risk of morbidity and mortality”.

Since the elements of frailty have an “incremental value in predicting worse outcomes” compared to individual elements alone, “this supports the use of a holistic approach to assessing frailty in outpatients with heart failure,” she added.

The research was presented at the British Cardiovascular Society’s 2021 annual conference on June 7th.

No consensus on frailty

Dr. Sze first stated that heart failure and frailty “often coexist, but are different units despite the overlapping pathophysiology, symptoms and prognosis”.

Furthermore, “although the concept of frailty is used extensively in clinical and research settings, there is currently no consensus definition or validated tool” to identify it in patients with heart failure.

A four-domain approach to frailty has been proposed, as in the recent position paper on frailty in patients with heart failure by the Heart Failure Association of the European Society of Cardiology.

Dr. However, Sze said that “the effectiveness of such an approach in detecting weaknesses in predicting outcomes in patients with heart failure is unknown”.

The team therefore set out to determine the prevalence and prognostic value of clinical, physical, cognitive, and social frailty in outpatients with heart failure and prospectively studied 467 consecutive patients attending a community heart failure clinic.

Clinical frailty was defined as having at least five non-heart failure comorbidities, while physical frailty was considered present when patients scored at least 3 on the Fried criteria.

Patients who did not take a clock test accurately were classified as cognitive deficits, while those who lived alone or in a residential or nursing home had a social deficit.

The mean age of the patients was 76 years, 67% were male. The average body mass index (BMI) was 29 kg / m2.

22% of patients had New York Heart Association (NYHA) Class III / IV heart failure, while 62% were diagnosed with reduced ejection fraction (HFrEF) heart failure.

The mean value of the prognostic marker N-terminal per B-type natriuretic peptide (NT-proBNP) was 1156 ng / l.

The prevalence of clinical frailty was 65%, while 52% had physical frailty, 39% had social frailty, and 18% had cognitive frailty. A deficit was recorded in 29% of the patients, 28% had two deficits, 19% three deficits and 8% four, while 16% had no deficits.

“There was considerable overlap between the different areas of frailty deficits,” said Sze, “but the overlap was not absolute, suggesting that each deficit represents a specific characteristic of frailty.”

Increasing numbers of frailty deficits are associated with older age, females and worse heart failure in the NYHA classification, he said, “and these patients are less likely to be prescribed guideline-indicated heart failure treatment.”

Follow up

Over a median follow-up of 554 days, 18% of the patients died.

A clinical deficit significantly increased the risk of death with a hazard ratio (HR) of 3.9, as did a physical deficit (HR = 4.7), a cognitive deficit (HR = 2.8) and a social deficit (HR = 2, 1). (p <0.001 for all).

An increasing number of deficits was associated with an increase in all-cause mortality by HR versus no deficits of 1.7 for one deficit (p = 0.46), 4.8 for two deficits (p = 0.01), 9 , 7 for three deficits (p <0.001) and 15.8 for four deficits (p <0.001).

Looking at a composite endpoint of all-cause hospitalizations and all-cause mortality, which occurred in 43% of patients, the team found a similar frailty effect.

Clinical frailty significantly increased the risk of the combined outcome at a HR of 3.0, as did physical frailty at a HR of 3.0 and cognitive frailty at a HR of 2.5 (p <0.001 for all), while social frailty a more marginal influence, with a HR of 1.2 (p = 0.16).

Here, too, an increasing number of deficits increased the risk of the combined outcome, from an HR for one deficit versus no deficits of 1.6 (p = 0.13), an HR of 2.9 for two deficits (p <0.001), 4.5 for three deficits (p <0.001) and 8.4 for four deficits.

Using a baseline model for age, BMI, NYHF classification, and the log of NT-proBNP, the researchers showed that adding each deficit increases the predictive power of the model, whether it is 1-year mortality or the combined Result after one year.

However, adding all four deficits had the greatest effect and increased the predictive power of the model for one-year all-cause mortality from 0.782 to 0821 (p = 0.001) and that for the combined result after 1 year from 0.705 to 0.735 (p <0.001).

Dr. Sze concluded that she “looks forward to further studies to evaluate how a domain management model can be used to optimize care for frail patients with heart failure.”

No funding indicated.

No relevant financial relationships indicated.

British Cardiovascular Society Annual Conference 2021: Abstract 114. Presented June 7th.

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