Documente Academic
Documente Profesional
Documente Cultură
10 2016
Brief Report
Frailty Assessment in Advanced Heart Failure
SHIVANK A. MADAN, MD, MHA,1 NADIA FIDA, MD,2 POULAMI BARMAN, MS,3 DANIEL SIMS, MD,1 JOOYOUNG SHIN, MD,1
JOE VERGHESE, MD,4 ILEANA PIA, MD, MPH,1 ULRICH JORDE, MD,1 AND SNEHAL R. PATEL, MD1
Bronx, New York; Houston, Texas; and Rochester, Minnesota
ABSTRACT
Background: Several studies have recently demonstrated the value of frailty assessment in a general heart
failure (HF) population; however, it is unknown whether these findings are also applicable in advanced HF.
We investigated the utility of frailty assessment and its prognostic value in elderly patients with advanced
HF.
Methods: Forty consecutive elderly subjects aged 65 years, with left ventricular ejection frac-
tion 35%, New York Heart Association class III or IV, and a 6-minute walk test <300 m were enrolled
from the HF clinic at Montefiore Medical Center between October 2012 and July 2013. Subjects were as-
sessed for frailty with the Fried Frailty Index, consisting of 5 components: hand grip strength, 15-foot walk
time, weight loss, physical activity, and exhaustion. All subjects were prospectively followed for death or
hospitalization.
Results: At baseline, the mean age of the cohort was 74.9 6.5 years, 58% female, left ventricular ejec-
tion fraction 25.6 6.4%, 6-minute walk test 195.8 74.3 m and length of follow-up 454 186 days. Thirty-
five percent were prefrail and 65% were frail. Frailty status was associated with the combined primary endpoint
of mortality and all-cause hospitalization (hazard ratio [HR] 1.93, 95% confidence interval [CI] 1.15
3.25, P = .013). On individual analysis, frailty was associated with all-cause hospitalizations (HR 1.92, 95%
CI 1.123.27, P = .017) and non-HF hospitalizations (HR 3.31, 95% CI 1.14- 9.6, P = .028), but was not
associated with HF hospitalizations alone (HR 1.31, 95% CI 0.682.49, P = .380).
Conclusions: Frailty assessment in patients with advanced HF is feasible and provides prognostic value.
These findings warrant validation in a larger cohort. (J Cardiac Fail 2016;22:840844)
Key Words: Frailty, heart failure, elderly, advanced heart failure, hospitalization, mortality.
Frailty is a biological syndrome defined as a decreased ho- in the general heart failure (HF) population have demon-
meostatic reserve leading to an increased vulnerability to strated that frailty is associated with increased health care
stressors and adverse outcomes.1 Frailty manifests clinical- utilization, hospitalizations, mortality,35 and incident HF.6
ly as a disproportionate change in health status in response When HF reaches more advanced states, it manifests similar
to a physical or psychological stress.2 Several recent studies to frailty, as a biological syndrome where the primary insult
is cardiac dysfunction but leads to systemic consequences.
From the 1Division of Cardiology, Department of Medicine, Montefiore Because of this significant overlap, the utility of frailty as-
Medical Center, Albert Einstein College of Medicine, Bronx, New York; 2Di- sessment in advanced HF is unclear. The aim of the current
vision of Cardiology, Department of Medicine, Houston Methodist Hospital,
Houston, Texas; 3Department of Health Sciences Research, Division of Bio-
study was to investigate the utility of frailty assessment and
medical Statistics and Informatics Mayo Clinic, Rochester, Minnesota and its prognostic value in elderly patients with advanced HF.
4
Division of Geriatrics, Department of Medicine, Montefiore Medical Center,
Albert Einstein College of Medicine, Bronx, New York.
Reprint requests: Snehal R. Patel, MD, Division of Cardiology, Heart
Failure, Cardiac Transplantation and Mechanical Circulatory Support, 3400
Methods
Bainbridge Avenue, Medical Arts Pavilion- 7th floor, Bronx, New York 10467.
Tel: +1 718 920 2248; Fax: +1 718 652 1833. E-mail: SNEPATEL@ In this single-center pilot study, consecutive patients from
montefiore.org.
Manuscript received November 20, 2015; revised manuscript received Montefiore Medical Center HF Clinic, between October 2012
February 3, 2016; revised manuscript accepted February 5, 2016. and July 2013, aged 65 years, New York Heart Associa-
See page 843 for disclosure information. tion (NYHA) class III or IV, and left ventricular ejection
1071-9164/$ - see front matter
2016 Elsevier Inc. All rights reserved. fraction (LVEF) 35% (measured by echocardiogram within
http://dx.doi.org/10.1016/j.cardfail.2016.02.003 30 days of the study visit) were screened to participate. Key
840
Descargado de ClinicalKey.es desde Universidad Nacional Autonoma de Mexico febrero 01, 2017.
Para uso personal exclusivamente. No se permiten otros usos sin autorizacin. Copyright 2017. Elsevier Inc. Todos los derechos reservados.
Frailty Assessment in Advanced Heart Failure Madan et al 841
Statistical Analysis
Results
Descargado de ClinicalKey.es desde Universidad Nacional Autonoma de Mexico febrero 01, 2017.
Para uso personal exclusivamente. No se permiten otros usos sin autorizacin. Copyright 2017. Elsevier Inc. Todos los derechos reservados.
842 Journal of Cardiac Failure Vol. 22 No. 10 October 2016
Table 1. Baseline Demographics of the Overall Cohort and as analyzed by the Prefrail and Frail Groups
Total (n = 40) Pre-frail (n = 14) Frail (n = 26) P Value: Pre-frail vs Frail
Age (y) 74.9 6.5 76.0 5.3 74.4 7.2 .475*
Sex (F) 23 (57.5%) 6 (42.8%) 17 (65.4%) .169
Race: Whites 4 (10%) 2 (14%) 2 (7.7%) .342
Blacks 16 (40%) 3 (21.4%) 13 (50.0%)
Hispanics 17 (42.5%) 8 (57.1%) 9 (34.6%)
Asians/others 3 (7.5%) 1 (7.1%) 2 (7.7%)
LVEF (%) 25.6 6.4% 26 5.5 25.3 6.9 .750*
NYHA class (IV) 15 (37.5%) 5 (35.7%) 10 (38.4%) .738
LVEDD (cm) 5.96 0.87 5.82 0.76 6.01 0.93 .600*
HTN 35 (87.5%) 13 (92.8%) 22 (84.6%) .452
DM 22 (55%) 11 (78.5%) 11 (42.3%) .028
Atrial fibrillation 17 (42.5%) 4 (28.6%) 13 (50%) .191
PAD 4 (10%) 2 (14.3%) 2 (7.7%) .507
GFR 46.9 22.4 47.7 16.9 46.5 25.2 .873*
HF etiology (ICM) 19 (47.5%) 8 (57.1%) 11 (42.3%) .37
HF duration (mo) 88.1 79.8 106.9 87.4 75.3 74.1 .320*
COPD 9 (22.5%) 5 (35.7%) 4 (15.4%) .142
Depression 8 (20%) 1 (7.1%) 7 (26.9%) .136
Medications
Beta-blockers 39 (97.5%) 13 (92.8%) 26 (100%) .168
ACEI/ARBs 32 (80%) 10 (71.4%) 22 (84.6%) .32
Aldosterone antagonists 20 (50%) 8 (57.1%) 12 (46.2%) .507
Hydralazine/nitrates 18 (45%) 6 (42.9%) 12 (46.2%) .842
6MWT (m) 195.8 74.3 192.4 68.06 197.7 78.71 .833*
Follow-up (d) 454 186 469.8 179.2 435.7 190.8 .585*
Charlson Comorbidity Index 4.9 1.9 4.2 0.7 5.2 2.3 .128*
ACEI, angiotensin-converting enzyme inhibitor; ARBs, angiotensin II receptor blockers; COPD, chronic obstructive pulmonary disease; DM, diabetes mel-
litus; F, female; GFR, glomerular filtration rate; HF, heart failure; HTN, hypertension; ICM, ischemic cardiomyopathy; LVEDD, left ventricle end diastolic
diameter; LVEF, left ventricular ejection fraction; 6MWT, 6-minute walking test; NYHA, New York Heart Association; PAD, peripheral arterial disease.
Boldface type indicates p value of <.05.
*Unpaired t test.
Chi square test.
Descargado de ClinicalKey.es desde Universidad Nacional Autonoma de Mexico febrero 01, 2017.
Para uso personal exclusivamente. No se permiten otros usos sin autorizacin. Copyright 2017. Elsevier Inc. Todos los derechos reservados.
Frailty Assessment in Advanced Heart Failure Madan et al 843
Fig. 2. Kaplan-Meier survival analysis modified for Andersen Gill modeling. Probability of freedom from (A) all-cause hospitalization and
death, (B) all-cause hospitalization, (C) heart failure hospitalizations only, and (D) non-heart failure hospitalizations in prefrail vs frail sub-
jects. Corresponding P values are shown in the graphs.
of less sick HF patients.11 In contrast, we did not find a sig- clinical prognostic value. These are intriguing findings that
nificant correlation between 6MWT and frailty. This is require validation in a larger cohort.
likely because our cohort was predefined based on 6MWT
(<300 m), limiting the variability of this measurement in the
Disclosures
study population. Regardless of this discrepancy, our find-
ings highlight that frailty assessment can have added prognostic
value in HF patients with a very poor 6MWT. There are no financial disclosures or conflict of interest for
There are several limitations to the current study. First, this any of the authors in regards to this publication.
is a single-center pilot study with a small sample size and
the findings need validation in a larger cohort. Second, we Acknowledgments
chose to use the most accepted frailty toolthe Fried Frailty
Index; however, several other frailty assessment tools have This research was funded by Division of Cardiology,
been validated, which were not incorporated. Although the Montefiore Medical Center, Albert Einstein College of
original Fried Frailty Index used a weighted score of kilo- Medicine, Bronx, NY.
calories per week for assessment of low physical activity, we
used a questionnaire to measure physical activity levels. This
modified version has been validated in previous studies.12 Third, Appendix: Supplementary material
we did not compare the predictive value of frailty to other
prognostication tools such as cardiopulmonary stress testing Supplementary data to this article can be found online at
or the Seattle HF Model.13 Finally, because of the small sample doi:10.1016/j.cardfail.2016.02.003.
size, we did not include many covariates that could affect hos-
pitalization rates (like NT pro-BNP levels, chronic obstructive
References
pulmonary disease, depression) into our multivariate model;
however, we did include the CCI as a measure of the global
1. Fried LP, Ferrucci L, Darer J, Williamson JD, Anderson G. Untangling
burden of comorbidity14 in the multivariate analysis. the concepts of disability, frailty, and comorbidity: implications for
In conclusion, our data demonstrate that frailty testing in improved targeting and care. J Gerontol A Biol Sci Med Sci
elderly patients with advanced HF is feasible and provides 2004;59:M25563.
Descargado de ClinicalKey.es desde Universidad Nacional Autonoma de Mexico febrero 01, 2017.
Para uso personal exclusivamente. No se permiten otros usos sin autorizacin. Copyright 2017. Elsevier Inc. Todos los derechos reservados.
844 Journal of Cardiac Failure Vol. 22 No. 10 October 2016
2. Fried LP, Tangen CM, Walston J, Newman AB, Hirsch C, Gottdiener 8. Guo Z, Gill TM, Allore HG. Modeling repeated time-to-event health
J, et al. Frailty in older adults evidence for a phenotype. J Gerontol A conditions with discontinuous risk intervals: an example of a longitudinal
Biol Sci Med Sci 2001;56:M14657. study of functional disability among older persons. Methods Inf Med
3. Cacciatore F, Abete P, Mazzella F, Viati L, Della Morte D, DAmbrosio 2008;47:107.
D, et al. Frailty predicts long-term mortality in elderly subjects with 9. Andersen PK, Gill RD. Coxs regression model for counting processes:
chronic heart failure. Eur J Clin Invest 2005;35:72330. a large sample study. Ann Stat 1982;110020.
4. Chaudhry SI, McAvay G, Chen S, Whitson H, Newman AB, Krumholz 10. Cahalin LP, Mathier MA, Semigran MJ, Dec GW, DiSalvo TG. The
HM, et al. Risk factors for hospital admission among older persons with six-minute walk test predicts peak oxygen uptake and survival in patients
newly diagnosed heart failure: findings from the cardiovascular health with advanced heart failure. CHEST J 1996;110:32532.
study. J Am Coll Cardiol 2013;61:63542. 11. Boxer R, Kleppinger A, Ahmad A, Annis K, Hager D, Kenny A. The
5. McNallan SM, Singh M, Chamberlain AM, Kane RL, Dunlay SM, 6-minute walk is associated with frailty and predicts mortality in older
Redfield MM, et al. Frailty and healthcare utilization among patients adults with heart failure. Congest Heart Fail 2010;16:20813.
with heart failure in the community. JACC Heart Fail 2013;1:13541. 12. Verghese J, Holtzer R, Lipton RB, Wang C. Mobility stress test approach
6. Khan H, Kalogeropoulos AP, Georgiopoulou VV, Newman AB, Harris to predicting frailty, disability, and mortality in high-functioning older
TB, Rodondi N, et al. Frailty and risk for heart failure in older adults: adults. J Am Geriatr Soc 2012;60:19015.
the health, aging, and body composition study. Am Heart J 13. Levy WC, Mozaffarian D, Linker DT, Sutradhar SC, Anker SD, Cropp
2013;166:88794. AB, et al. The seattle heart failure model prediction of survival in heart
7. Rostagno C, Olivo G, Comeglio M, Boddi V, Banchelli M, Galanti G, failure. Circulation 2006;113:142433.
et al. Prognostic value of 6-minute walk corridor test in patients with 14. Henkel DM, Redfield MM, Weston SA, Gerber Y, Roger VL. Death
mild to moderate heart failure: comparison with other methods of in heart failure a community perspective. Circ Heart Fail 2008;1:
functional evaluation. Eur J Heart Fail 2003;5:24752. 917.
Descargado de ClinicalKey.es desde Universidad Nacional Autonoma de Mexico febrero 01, 2017.
Para uso personal exclusivamente. No se permiten otros usos sin autorizacin. Copyright 2017. Elsevier Inc. Todos los derechos reservados.