Holistic Approach Needed to Tackle Frailty in Heart Failure Patients

Liam Davenport

June 17, 2021

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

Dr Shirley Sze, NIHR Leicester Biomedical Research Centre, University of Leicester, and colleagues studied over 460 ambulatory heart failure patients, finding that each of the frailty deficits were present in at least 18% of 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 hospitalisation and death, but the presence of multiple deficits dramatically increased the risk.

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

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

As the elements of frailty had an "incremental value in predicting worse outcomes" compared with individual elements alone, this "supports the use of a holistic approach to evaluate frailty in ambulatory patients with heart failure", she added.

The research was presented at the British Cardiovascular Society 2021 Annual Conference on June 7.

No Frailty Consensus

Dr Sze began by noting that heart failure and frailty "often co-exist, but they are distinct entities, despite overlapping pathophysiology, symptoms and prognosis".

Moreover, "although the concept of frailty is used extensively in clinical and research settings, there is currently no consensus definition or a validated instrument" to identify it in heart failure patients.

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

However, Dr Sze said that the "efficacy of such an approach in detecting frailty in predicting outcomes in patients with heart failure is unknown".

The team therefore set to determine the prevalence and prognostic value of clinical, physical, cognitive and social frailty in ambulatory patients with heart failure, prospectively studying 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 deemed present if patients scored at least 3 on the Fried criteria.

Patients who failed to complete a clock test accurately were classified as having a cognitive deficit, while those living alone or in a residential or care home were said to have a social deficit.

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

Twenty-two per cent of the patients had New York Heart Association (NYHA) class III/IV heart failure, while heart failure with reduced ejection fraction (HFrEF) was detected in 62%.

The mean the prognostic marker N-terminal pro B-type natriuretic peptide (NT-proBNP) level was 1156 ng/L.

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

"There was considerable overlap between the different domains of frailty deficits," Sze said, "but the overlap was not absolute, suggesting that each deficit represents a distinct feature of frailty."

An increasing number of frailty deficits was associated with older age, female sex, and worse heart failure on the NYHA classification, he said, "and these patients were 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.

Having a clinical deficit significantly increased the risk of dying, at a hazard ratio (HR) of 3.9, as did having 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, rising from an 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 combined endpoint of all-cause hospitalisation and all-cause mortality, which was experienced by 43% of patients, the team found a similar impact of frailty.

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

Again, an increasing number of deficits increased the risk of the combined outcome, rising 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.

Working from a base model of age, BMI, NYHF Classification and the log of NT-proBNP, the researchers showed that adding each deficit increased the predictive of power of the model, whether looking at 1-year mortality or the combined outcome at one year.

Adding all four deficits, however, had the greatest impact, increasing 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 outcome at 1 year from 0.705 to 0.735 (p<0.001).

Dr Sze concluded that she looks "forward to further studies to evaluate how care can be optimised for frail patients with heart failure using a domain management model".

No funding declared.

No relevant financial relationships declared.

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

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