Frailty in Heart Failure

Excess Mortality and Hospitalizations Associated With Seasonal Influenza in Patients With Heart Failure

BACKGROUND

Influenza virus may cause severe infection in patients with heart failure. It is known that influenza infection is associated with increased morbidity and mortality in patients with heart failure. However, less is known about the excess burden of morbidity and mortality caused by influenza infection in patients with heart failure at a population level.

OBJECTIVES

The purpose of this study was to estimate the excess burden of morbidity and mortality as determined by annual excess number of deaths and hospitalizations associated with influenza infection in patients with heart failure in Denmark.

METHODS

We collected nationwide data on weekly number of deaths and hospitalizations among patients with heart failure in Denmark and weekly estimates of influenza circulation as determined by the proportion of positive influenza samples analyzed at all Danish Hospitals. These data were correlated in a time series linear regression model, and this model was used to estimate the annual excess number of deaths and hospitalizations attributable to influenza circulation among patients with heart failure in Denmark. The model also included data on weekly mean temperature and restricted cubic spline terms to account for seasonality and trends over time.

RESULTS

Data were available from 2010 to 2018 encompassing 8 influenza seasons with an annual mean of 25,180 samples tested for influenza at Danish hospitals. Among an annual mean of 70,570 patients with heart failure, our model estimated that influenza activity was associated with an annual excess of 250 all-cause deaths (95% CI: 144-489 deaths) corresponding to 2.6% of all all-cause deaths (95% CI: 1.5%-5.1%) in patients with heart failure. Similarly, influenza activity was associated with an annual excess of 115 cardiovascular deaths (95% CI: 62-244 deaths) corresponding to 2.9% of all cardiovascular deaths (95% CI: 1.5%-6.1%). Influenza activity was also associated with an annual excess of 251 hospitalizations for pneumonia or influenza (95% CI: 107-533 hospitalizations) corresponding to 5.0% of all hospitalizations for pneumonia or influenza.

CONCLUSIONS

Our results indicate that influenza activity likely causes substantial morbidity and mortality among patients with heart failure. Notably, our study suggests that approximately 2.6% of all deaths and 5.0% of all hospitalizations with influenza or pneumonia may be attributed to influenza in patients with heart failure.

ECMO as a bridge to heart transplantation: Insights into stratification by heart failure etiology

Background

Revisions to the heart allocation criteria in 2018 motivated an increased use of extracorporeal membrane oxygenation (ECMO) as a bridge to transplantation. Studies have demonstrated inferior post-transplant outcomes in patients bridged with ECMO but do not account for underlying diagnosis. Our objective was to elucidate the differential impact of ECMO on outcomes by heart failure (HF) etiology.

Methods

The United Network of Organ Sharing database was queried for adults who underwent isolated heart transplantation after October 2018. Patients were stratified by ECMO utilization at the time of transplantation and then by HF etiology. After baseline statistical comparisons, survival analysis relied on Kaplan-Meier estimates and Cox proportional models.

Results

A total of 13,203 patients were included, of whom 761 (5.8%) were supported with ECMO. ECMO patients were younger (48 vs 54 years, p < 0.001), less likely to have diabetes (24% vs 30%, p < 0.001), smoke cigarettes (31% vs 41%, p < 0.001), or have prior cardiac surgery (29% vs 36%, p < 0.001), more likely to require dialysis (20% vs 5%, p < 0.001), and spent fewer days on the waitlist (59 vs 190, p < 0.001). After adjustment, ECMO was associated with increased mortality (hazard ratio 1.85, p < 0.001) in the full cohort. After incorporating HF etiology, this increased mortality risk persisted in all subgroups except restrictive cardiomyopathy and congenital heart disease (CHD).

Conclusions

Our findings illustrate that HF etiology is associated with differing outcomes when bridging with ECMO. ECMO patients with restrictive cardiomyopathy or CHD did not have increased mortality risk. With ECMO utilization increasing, these data are hypothesis-generating and serve as a basis for further studies.

Pectoral muscle mass is not a robust prognostic factor for survival after left ventricular assist device (LVAD) implantation

BACKGROUND

Left ventricular assist devices (LVAD) are an established treatment for end-stage left ventricular heart failure. Parameters are needed to identify the most appropriate patients for LVADs. This study aimed to evaluate pectoral muscle mass and density as prognostic parameters.

METHODS

This single-center study included all patients with LVAD implantation between January 2010 and October 2017 and a preoperative chest CT scan. Pectoral muscle mass was assessed using the Pectoralis Muscle Index (PMI, surface area indexed to height, cm2/m2) and pectoral muscle density by Hounsfield Units (HU). Overall mortality was analyzed with Kaplan-Meier survival analysis and 1-year and 3-year mortality with receiver operating characteristic (ROC) curves and Cox regression models.

RESULTS

57 patients (89.5% male, mean age 57.8 years) were included. 64.9% of patients had end-stage left ventricular failure due to ischemic heart disease and 35.1% due to dilated cardiomyopathy. 49.2% of patients had preoperative INTERMACS profile of 1 or 2 and 33.3% received mechanical circulatory support prior to LVAD implantation. Total mean PMI was 4.7 cm2/m2 (± 1.6), overall HU of the major pectoral muscle was 39.0 (± 14.9) and of the minor pectoral muscle 37.1 (± 16.6). Mean follow-up was 2.8 years (± 0.2). Mortality rates were 37.5% at 1 year and 48.0% at 3 years. Neither PMI nor HU were significantly associated with overall mortality at 1-year or 3-year.

CONCLUSIONS

The results of our study do not confirm the association between higher pectoral muscle mass and better survival after LVAD implantation previously described in the literature.

The impact of cardiopulmonary rehabilitation in phase II cardiac rehabilitation program on the health-related quality of life of patients undergoing coronary artery bypass graft surgery

BACKGROUND

Coronary artery bypass surgery is the leading cause of change in the quality of life and pulmonary function of patients. One strategy to enhance lung muscle strength and improve overall quality of life is pulmonary rehabilitation. This study aimed to investigate the impact of incorporating a pulmonary rehabilitation program into phase II cardiac rehabilitation program on the quality of life of patients undergoing coronary artery bypass graft surgery.

METHODS

This randomized clinical trial study included 53 patients who underwent coronary artery bypass graft surgery at Imam Reza Hospital in Mashhad between September 2019 and March 2020. The research participants were selected based on specific inclusion criteria and divided into two groups. The control group followed the routine rehabilitation program, whereas the intervention group underwent a pulmonary rehabilitation program for 20-30 min after each session of the cardiac rehabilitation program. Data collection tools included a demographic information questionnaire and the Ferrans and Powers' quality of life index. The data were analyzed using the independent t-test, Mann-Whitney test, paired t-test, Spearman correlation, Wilcoxon test, and SPSS25.

RESULTS

The mean quality of life score in the intervention group(20.7±1.8) was significantly higher than that of the control group (18.8±2.3)(P < 0.05). Furthermore, the intervention group exhibited significantly higher mean scores in the physical, psychological-spiritual, and family dimensions than the control group(P < 0.05).

CONCLUSION

The study results demonstrate the positive impact of incorporating a pulmonary rehabilitation program into cardiac rehabilitation on the health-related quality of life of patients undergoing coronary artery bypass graft surgery.

TRIAL REGISTRATION

IRCT20190707044132N1.

Cardiac rehabilitation engagement and associated factors among heart failure patients: a cross-sectional study

BACKGROUND

Chronic Heart Failure (CHF) still affects millions of people worldwide despite great advances in therapeutic approaches in the cardiovascular field. Cardiac rehabilitation (CR) is known to improve disease-related symptoms, quality of life and clinical outcomes, yet implementation is suboptimal, a frequently low engagement in rehabilitation programs has been found globally.

OBJECTIVE

To quantify diverse CR-engaged processes and elucidate associated factors of the various levels of CR engagement in CHF patients.

METHODS

Discharged patients admitted from cardiology departments between May 2022 to July 2022 were enrolled by mobile phone text messaging, CHF patients from same department between August 2022 to December 2022 were enrolled by face-to-face. Individuals who met the inclusion criteria filled the questionnaires, including the generalized anxiety disorders scale, patient health questionnaire, cardiac rehabilitation inventory, patient activation measure, Tampa scale for kinesiophobia heart, social frailty, Patient Health Engagement Scale (PHE-s®). We obtained sociodemographic characteristics and clinical data from medical records. Chi-square tests and multivariable logistic regression analyses were performed to examine the factors associated with CR engagement phases.

RESULTS

A total of 684 patients were included in the study. 52.49% patients were in the Adhesion phase. At the multivariate level, compared with the blackout phase process anxiety, monthly income (RMB yuan) equal to or more than 5,000 were the most important factor impacting CHF patients CR engagement. Compared with the Blackout phase, regular exercise or not, severe depression, previous cardiac-related hospitalizations 1 or 2 times, Age influenced patient CR engagement in the Arousal phase. Besides, compared with the Blackout phase, outcome anxiety and activation level were independent factors in the Eudaimonic Project phase.

CONCLUSION

This study characterized CR engagement, and explored demographic, medical, and psychological factors-with the most important being process anxiety, monthly income, patient activation, severe depression, and previous cardiac-related hospitalizations. The associated factors of CR engagement were not identical among different phases. Our findings suggested that factors could potentially be targeted in clinical practice to identify low CR engagement patients, and strategies implemented to strengthen or overcome these associations to address low CR engagement in CHF patients.

The Aging Heart: A Molecular and Clinical Challenge

Aging is associated with an increasing burden of morbidity, especially for cardiovascular diseases (CVDs). General cardiovascular risk factors, ischemic heart diseases, heart failure, arrhythmias, and cardiomyopathies present a significant prevalence in older people, and are characterized by peculiar clinical manifestations that have distinct features compared with the same conditions in a younger population. Remarkably, the aging heart phenotype in both healthy individuals and patients with CVD reflects modifications at the cellular level. An improvement in the knowledge of the physiological and pathological molecular mechanisms underlying cardiac aging could improve clinical management of older patients and offer new therapeutic targets.

Assessment of frailty and related outcomes in older patients with heart failure: A cohort study

OBJECTIVE

Heart failure (HF) is a common cause of morbidity and mortality in older patients. Frailty is prevalent and complicates the course of HF. We sought to investigate the impact of frailty on HF outcomes.

METHODS

Patients over 65 years old hospitalized with acute decompensated HF and mildly reduced or preserved EF, between September 2017 and September 2019 were enrolled in the study. Before hospital discharge at euvolemic state, patients underwent six-minute walk test (6MWT) and frailty assessment using FRIED and modified SOF scores. Predictors of death, readmissions, and increase in diuretic dose were analyzed by multivariable logistic regression models.

RESULTS

We enrolled 193 consecutive patients (mean age 78.6 ± 8.4 years, 29.5% males, 59.6% with HF and preserved EF). All patients had at least one comorbidity (40.9% coronary artery disease, 71% diabetes, and 86% hypertension). The mean 6MWT distance was 316.2 meters. According to FRIED score, 4.7% were normal and 17.6% were categorized as pre-frail and 77.7% as frail, while according to SOF index 9.8% were normal, 15% were categorized as pre-frail and 75.1% as frail. Frail patients according to both indices had a higher risk of 90-day readmissions, uptitration of diuretics within 90 days (p < 0.001 for both) and numerically but not significantly higher risk of death. Frailty status was independently associated with higher risk of 90-day readmissions, uptitration of diuretics, and higher BNP at 90 days.

CONCLUSIONS

Frailty in older patients with HF is common and associated with worse prognosis. Pre-discharge frailty assessment may aid in identification of patients at high-risk for short-term complications.

Frailty as a predictor of clinical problems and events that require elderly patients with heart failure to use health resources

BACKGROUND

The clinical management of elderly patients with heart failure (HF) is not firmly established. Decision-making should be individualized depending on the biological deterioration of each patient, from aggressive management to a palliative approach. Frailty can serve as the basis for this comprehensive individualized management. Our objective was to evaluate the importance of the main clinical problems, as well as the events that required the use of health resources, based the degree of frailty, in elderly patients with HF.

METHODS AND RESULTS

Retrospective observational cohort study. Frailty was defined according to the deficit accumulation construct. A total of 546 patients hospitalized for acute HF were included. The median age (Q1-Q3) was 82 (78-86) years. A total of 454 patients (83%) showed some degree of frailty: 221 (48.7%) mild, 207 (45.6%) moderate and 26 (5.7%) advanced. There was a significant tendency towards polypharmacy from no to severe frailty. Hospital events were recorded for 4 (1-6) patients with mild frailty, 4 (2-6) patients with moderate frailty and 2 ((1-4) patients with advanced frailty (p = 0.045). A total of 204 patients (37.4%) died during follow-up. The median time to death was 11.4 (4-16.8), 6.7 (3.3-11.6), 6.5 (3.4-12.2) and 4.1 (0.8-7.7) months for patients with no, mild, moderate, or advanced frailty, respectively (p = 0.006).

CONCLUSIONS

Frailty due to deficit accumulation is a good predictor of clinical problems and events that require the use of health resources; therefore, it can serve as a basis for the management of HF in the elderly.

The Impact of Frailty and Comorbidities on Heart Failure Outcomes

Frailty is a multisystemic process leading to reduction of physiological reserve and a reduction in physical activity. Heart failure (HF) is recognised as a global cause of morbidity and mortality, increasing in prevalence over recent decades. Because of shared phenotypes and comorbidities, there is significant overlap and a bidirectional relationship, with frail patients being at increased risk of developing HF and vice versa. Despite this, frailty is not routinely assessed in patients with HF. Identification of these patients to direct multidisciplinary care is key, and the development of a frailty assessment tool validated in a large HF population is also an unmet need that would be of considerable benefit in directing multidisciplinary-team management. Non-pharmacological treatment should be included, as exercise and physical rehabilitation programmes offer dual benefit in frail HF patients, by treating both conditions simultaneously. The evidence for nutritional supplementation is mixed, but there is evidence that a personalised approach to nutritional support in frail HF patients can improve outcomes.

Frailty assessment using a novel approach based on combined motor and cardiac functions: a pilot study

BACKGROUND

Previous research showed association between frailty and an impaired autonomic nervous system; however, the direct effect of frailty on heart rate (HR) behavior during physical activity is unclear. The purpose of the current study was to determine the association between HR increase and decrease with frailty during a localized upper-extremity function (UEF) task to establish a multimodal frailty test.

METHODS

Older adults aged 65 or older were recruited and performed the UEF task of rapid elbow flexion for 20 s with the right arm. Wearable gyroscopes were used to measure forearm and upper-arm motion, and electrocardiography were recorded using leads on the left chest. Using this setup, HR dynamics were measured, including time to peak HR, recovery time, percentage increase in HR during UEF, and percentage decrease in HR during recovery after UEF.

RESULTS

Fifty-six eligible participants were recruited, including 12 non-frail (age = 76.92 ± 7.32 years), and 40 pre-frail (age = 80.53 ± 8.12 years), and four frail individuals (age = 88.25 ± 4.43 years). Analysis of variance models showed that the percentage increase in HR during UEF and percentage decrease in HR during recovery were both 47% smaller in pre-frail/frail older adults compared to non-frails (p < 0.01, effect size = 0.70 and 0.62 for increase and decrease percentages). Using logistic models with both UEF kinematics and HR parameters as independent variables, frailty was predicted with a sensitivity of 0.82 and specificity of 0.83.

CONCLUSION

Current findings showed evidence of strong association between HR dynamics and frailty. It is suggested that combining kinematics and HR data in a multimodal model may provide a promising objective tool for frailty assessment.

The association between heart rate behavior and gait performance: The moderating effect of frailty

Introduction

Research suggests that frailty not only influence individual systems, but also it affects the interconnection between them. However, no study exists to show how the interplay between cardiovascular and motor performance is compromised with frailty.

Aim

To investigate the effect of frailty on the association between heart rate (HR) dynamics and gait performance.

Methods

Eighty-five older adults (≥65 years and able to walk 9.14 meters) were recruited (October 2016—March 2018) and categorized into 26 non-frail (age = 78.65±7.46 years) and 59 pre-frail/frail individuals (age = 81.01±8.17) based on the Fried frailty phenotype. Participants performed gait tasks while equipped with a wearable electrocardiogram (ECG) sensor attached to the chest, as well as wearable gyroscopes for gait assessment. HR dynamic parameters were extracted, including time to peak HR and percentage increase in HR in response to walking. Using the gyroscope sensors gait parameters were recorded including stride length, stride velocity, mean swing velocity, and double support.

Results

Among the pre-frail/frail group, time to peak HR was significantly correlated with all gait parameters (p<0.0001, r = 0.51–0.59); however, for the non-frail group, none of the correlations between HR dynamics and gait performance parameters were significant (p>0.45, r = 0.03–0.15). The moderation analysis of time to peak HR, demonstrated a significant interaction effect of HR dynamics and frailty status on walking velocity (p<0.01), and the interaction effect was marginally non-significant for other gait parameters (p>0.10).

Conclusions

Current findings, for the first time, suggest that a compromised motor and cardiac autonomic interaction exist among pre-frail/frail older adults; an impaired HR performance (i.e., slower increase of HR in response to stressors) may lead to a slower walking performance. Assessing physical performance and its corresponding HR behavior should be studied as a tool for frailty screening and providing insights about the underlying cardiovascular-related mechanism leading to physical frailty.

Exploring the Relationship between Frailty, Functional Status, Polypharmacy, and Quality of Life in Elderly and Middle-Aged Patients with Cardiovascular Diseases: A One-Year Follow-Up Study

The association between frailty, disability in activities of daily living (ADL), polypharmacy, and quality of life (QoL) in middle-aged patients with cardiovascular disease (CVD) is little investigated. This study sought (a) to explore this association comparatively in elderly and middle-aged hospitalized patients with CVD and (b) to determine which domains of ADL and QoL might improve the frailty prediction. A one-year follow-up study including 90 elderly (≥65 years old) and 89 middle-aged patients (40-65 years old) was conducted. At baseline, frailty assessment was performed based on the Fried criteria; Barthel Index (BI) and Duke Activity Status Index (DASI) were used for ADL, and European Quality of Life-5 dimensions (EQ-5D) for QoL. At follow-up, data were collected via telephone. At baseline, 79 patients (51 elderly and 28 middle-aged) were frail. The CVD frail patients showed functional dependency and a poor QoL compared to the non-frail (p < 0.001) and within each subgroup at follow-up. Mobility was found to predict frailty in both elderly (OR = 2.34) (C.I. (1.03-5.29)) and middle-aged patients (OR = 2.58) (C.I. (1.15-5.78)). The ADL assessment and self-reported QoL may help to identify an aggravation or an advanced frailty condition in hospitalized elderly and middle-aged CVD patients.

Impact of Melatonin and Branched-Chain Amino Acids Cosupplementation on Quality of Life, Fatigue, and Nutritional Status in Cachectic Heart Failure Patients: A Randomized Controlled Trial

Background: Cardiac cachexia (CC) adversely affects the lifestyle of heart failure (HF) patients. The current study examined the impact of melatonin cosupplementation and branched-chain amino acids (BCAAs) on quality of life (QoL), fatigue, and nutritional status in cachectic HF patients. Methods: In this trial, 84 CC patients were randomized to melatonin, BCAAs, or coadministration (both) as intervention groups and a control group over 8 weeks. At baseline and postintervention, QoL, fatigue, and nutritional status were assessed. Results: After intervention, improvement in the overall and physical dimensions of QoL and appetite score were found to be statistically significant in the BCAAs (P < .001) and the melatonin+BCAAs (P < .001) groups compared with the placebo group. The emotional dimension score was significantly lower in the BCAAs group compared with the placebo group (P = .001). There was a statistically significant improvement in fatigue severity in all 3 intervention groups compared with the placebo group. The nutrition risk index (NRI) score increased significantly only in the melatonin group (P = .015), and there was no significant difference between the other groups (P = .804). Conclusions: Cosupplementation with BCAAs and melatonin improved QoL, fatigue status, and appetite in cachectic HF patients but did not affect NRI.

Comprehensive geriatric assessment in elderly and senile patients with cardiovascular diseases. Expert opinion of the Russian Association of Gerontologists and Geriatricians

Senile asthenia syndrome (SAS) is a geriatric syndrome characterized by age-associated decline of the physiological reserve and function in multiple systems, which results in higher vulnerability to effects of endo- and exogenous factors and a high risk of unfavorable outcomes, loss of self-sufficiency, and death. Generally, SAS is observed in elderly patients with comorbidities. In cardiovascular diseases, SAS is associated with a poor prognosis, including a higher incidence of exacerbation and death both during acute events and in chronic disease. However, SAS is often not taken into account in developing diagnostic and therapeutic programs for managing elderly patients with cardiovascular diseases (CVD). This article analyzes available scientific information about SAS, algorithms for SAS diagnosis, and the scales that may be useful in developing individual plans for management of elderly patients with CVD.

Validation of Cognitive Impairment in Combination With Physical Frailty as a Predictor of Mortality in Patients With Advanced Heart Failure Referred for Heart Transplantation

BACKGROUND

The aim of this study was to validate our previous finding that frailty predicts early mortality in patients with advanced heart failure (AHF) and that including cognition in the frailty assessment enhances the prediction of mortality.

METHODS

Patients with AHF referred to our Transplant Unit between November 2015 and April 2020 underwent physical frailty assessment using the modified Fried physical frailty (PF) phenotype as well as cognitive assessment using the Montreal Cognitive Assessment (MOCA) to identify patients who were cognitively frail (CogF). We assessed the predictive value of the 2 frailty measures (PF ≥ 3 of 5 = frail; CogF ≥ 3 of 6 = frail) for pretransplant mortality.

RESULTS

313 patients (233 male, 80 female; age 53 ± 13 years) were assessed. Of these, 224 patients (72%) were nonfrail and 89 (28%) were frail using the PF. The cognitive frailty assessment identified an additional 30 patients as frail: 119 (38%). Frail patients had significantly increased mortality as compared to nonfrail patients. Ventricular assist device and heart transplant-censored survival at 12 months was 92 ± 2 % for nonfrail and 69 ± 5% for frail patients (p < 0.0001) using the CogF instrument.

CONCLUSIONS

This study validates our previously published findings that frailty is prevalent in patients with advanced heart failure referred for heart transplantation. Physical frailty predicts early mortality. The addition of cognitive assessment to the physical assessment of frailty identifies an additional cohort of patients with a similarly poor prognosis.

Cognition and Frailty in Patients With Heart Failure: A Systematic Review of the Association Between Frailty and Cognitive Impairment

Background/Aim: Pathological processes associated with aging increase the risk of cognitive deficits. Frailty syndrome may significantly accelerate these pathological processes in elderly patients with heart failure. The objective of this review was to better understand the association between frailty syndrome and co-occurring cognitive decline in patients with heart failure. Methods: We conducted a systematic review based on PubMed/MEDLINE, Scopus, EMBASE, and CINAHL as databases. The search followed the method described by Webb and Roe. For inclusions, the studies were selected employing cross-sectional and longitudinal designs. The included studies had to evaluate frailty syndrome and cognitive impairments among participants with heart failure. As we were interested in older adults, the search was limited to individuals >65 years of age. The search was limited to primary research articles written in English published since the year 2000. Results: Of the 1,245 studies retrieved by the systematic review, 8 relevant studies were enclosed for the full-text review. Our review revealed that most studies of patients with HF demonstrated evidence of an association between greater frailty and cognitive impairment. In particular, six studies reported evidence for the significant association between higher levels of frailty and cognitive impairment in patients with heart failure. The remaining two studies failed to find an association between frailty and cognitive impairment. Conclusions: The development of frailty and cognitive impairment in heart failure is particularly important because this cardiovascular disease is a common cause of both morbidity and mortality in the world. The results of this review fill the existing gap in the literature related to the identification of clinical factors linked with frailty syndrome that contribute to cognitive impairment in patients with a diagnosis of heart failure. The prevalence of overlapping frailty and cognitive impairment in patients with heart failure, therefore, necessitates a routine assessment of these components in the care of patients with cardiovascular disease.

Cognitive impairment in patients hospitalized for congestive heart failure: data from the RICA Registry

The objective of this study is to determine the prevalence of cognitive impairment (CogI) in patients hospitalized for congestive heart failure, and the influence of CogI on mortality and hospital readmission. This is a multicenter cohort study of patients hospitalized for congestive heart failure enrolled in the RICA registry. The patients were divided into 3 groups according to their Short Portable Mental Status Questionnaire score: 0-3 errors (no CogI or mild CogI), 4-7 (moderate CogI) and 8-10 (severe CogI). A total of 3845 patients with a mean (SD) age of 79 (8.6) years were included; 2038 (53%) were women. A total of 550 (14%) patients had moderate CogI and 76 (2%) had severe CogI. Factors independently associated with severe CogI were age (OR 1.09, 95% CI 1.05-1.14 p < 0.001), male sex (OR 0.57, 95% CI 0.34-0.95, p = 0.031), heart rate (OR 1.01, 95% CI 1.00-1.02, p = 0.004), Charlson index (OR 1.16, 95% CI 1.06-1.27, p = 0.002), and history of stroke (OR 2.67, 95% CI 1.60-4.44, p < 0.001). Severe CogI was associated with higher mortality after one year (HR 3.05, 95% CI 2.25-4.14, p < 0.001). The composite variable of death/hospital readmission was higher in patients with CogI (log rank p < 0.001). Patients with heart failure and severe CogI are older and have a higher comorbidity burden, lower survival, and a higher rate of death or readmission at 1 year, compared to patients with no CogI.

Frailty and heart response to physical activity

BACKGROUND

Although previous studies showed that frail older adults are more susceptible to develop cardiovascular diseases, the underlying effect of frailty on heart rate dynamics is still unclear. The goal of the current study was to measure heart rate changes due to normal speed and rapid walking among non-frail and pre-frail/frail older adults, and to implement heart rate dynamic measures to identify frailty status.

METHODS

Eighty-eight older adults (≥65 years) were recruited and stratified into frailty groups based on the five-component Fried frailty phenotype. While performing gait tests, heart rate was recorded using a wearable ECG and accelerometer sensors. Groups consisted of 27 non-frail (age = 78.70 ± 7.32) and 61 pre-frail/frail individuals (age = 81.00 ± 8.14). The parameters of interest included baseline heart rate measures (mean heart rate and heart rate variability), and heart rate dynamics due to walking (percentage change in heart rate and required time to reach the maximum heart rate).

RESULTS

Respectively for normal and rapid walking conditions, pre-frail/frail participants had 46% and 44% less increase in heart rate, and 49% and 27% slower occurrence of heart rate peak, when compared to non-frail older adults (p < 0.04, effect size = 0.71 ± 0.12). Measures of heart rate dynamics showed stronger associations with frailty status compared to baseline resting-state measures (sensitivity = 0.75 and specificity = 0.65 using heart rate dynamics measures, compared to sensitivity = 0.64 and specificity = 0.62 using baseline parameters).

CONCLUSIONS

These findings suggest that measures of heart rate dynamics in response to daily activities may provide meaningful markers for frailty screening.

Angina pectoris severity and late-life frailty among men with cardiovascular disease

OBJECTIVE

We investigated the association between severity of angina pectoris (AP) and subsequent late-life frailty among men with cardiovascular disease (CVD).

METHOD

A subset of 351 men (mean age at baseline 56.7 ± 6.5 years) who previously participated in the Bezafibrate Infarction Prevention, BIP trial (1990-1997) underwent a neurovascular evaluation as part of the BIP Neurocognitive study 15.0 ± 3.0 years after baseline (T1) and a frailty evaluation according to Fried 19.9 ± 1.0 years after baseline (T2). Severity of AP was assessed at baseline of the BIP trial using the Canadian Cardiovascular Society angina classification. We assessed the odds of being in the advanced rank of frailty status (robust, pre-frail, and frail) using ordered logistic regression.

RESULTS

Among 351 participants, 134 (38.2%) were classified as pre-frail and 100 (28.5%) as frail. Frailty was found among 42% participants in the AP class ≥2 and among 26% participants in the AP class <2. Adjusting for demographic, health-related and cognitive variables, odds ratio (OR), and 95% confidence interval (95% CI) for advanced rank of frailty was 2.68 (95% CI: 1.29-5.59) comparing AP class ≥2 to AP class <2.

DISCUSSION

Among men with CVD, severity of AP should be taken into risk consideration due to its strong association with late-life frailty, particularly among inactive participants and participants with cerebral microvascular damage.

Cardiac Cachexia: A Well-Known but Challenging Complication of Heart Failure

Heart failure (HF) is a common complication of various cardiac diseases, and its incidence constantly increases. This is caused mainly by aging of populations and improvement in the treatment of coronary artery disease. As HF patients age, they tend to develop comorbidities, creating new problems for health-care professionals. Sarcopenia, defined as the loss of muscle mass and function, and cachexia, defined as weight loss due to an underlying illness, are muscle wasting disorders of particular relevance in the heart failure population, but they go mostly unrecognized. The coexistence of chronic HF and metabolic disorders facilitates the development of cachexia. Cachexia, in turn, significantly worsens a patient’s prognosis and quality of life. The mechanisms underlying cachexia have not been explained yet and require further research. Understanding its background is crucial in the development of treatment strategies to prevent and treat tissue wasting. There are currently no specific European guidelines or recommended therapy for cachexia treatment in HF (“cardiac cachexia”).

Patient-Reported Compliance in older age patients with chronic heart failure

METHODS AND RESULTS

475 patients (including 222 women), mean age 69.7±7.7, with HF, hospitalized at University Hospital between January and December 2018 were included in the study. The patients were selected by a physician specializing in cardiology. A cardiac nurse assessed the non-pharmacological level of compliance using the Revised Heart Failure Compliance Questionnaire (RHFCQ). The socio-clinical data were obtained from medical records. The majority of the study group were patients in NYHA II (62.4%) and NYHA III (28.3%), the mean duration of the disease was 6.2±4.9 years, and the mean ejection fraction of the left ventricle (EF) was 48.6±12.6. The average level of compliance in the study group measured on a scale from 0 to 4 points was: median = 2.7, IQR [2.32; 3.25]. Only 6.9% of the respondents adhere to recommendations totally (all dimensions of RHFCQ). In univariate analysis, predictors negatively affecting compliance were: female gender (rho = -0.325), age below 65 years (rho = -0.014)), loneliness (rho = -0.559), number of hospitalizations (rho = -0.242), higher stage of NYHA (rho = -1.612), co-morbidities (rho = -0.729), re-hospitalizations (rho = -0.729), beta-blockers treatment (rho = -1.612) and diuretics treatment (rho = -0.276). Factors positively affecting compliance were: EF≥45% (rho = 0.020) and treatment with ACEI/ARB (rho = 0.34), whereas compliance was negatively affected by-EF<45% (β = 0.009). Independent predictors influencing the level of compliance were: loneliness (β = -1.816), number of hospitalizations (β = -0.117), NYHA III and IV and number of co-morbidities (β = -0.676).

CONCLUSIONS

Patients with HF do not adhere to therapeutic recommendations. The lowest compliance levels were found for exercise and daily weighing, and the highest for follow-up appointment-keeping and medication. Loneliness and age are the strongest predictors which influence the level of compliance.

Sacubitril/valsartan in patients listed for heart transplantation: effect on physical frailty

AIMS

The aim of this study was to investigate prospectively the effect of sacubitril/valsartan in advanced heart failure (HF) patients in waiting list for heart transplantation (HT) and the effect on physical frailty (PF).

METHODS AND RESULTS

We treated 37 consecutive patients with advanced HF with sacubitril/valsartan. Patients were followed up until HT, device implant, or last follow-up visit after 2 years of follow-up. At baseline, mean New York Heart Association (NYHA) class was 3.1 ± 0.4, with 64.9% in NYHA III and 35.1% NYHA IIIB. Left ventricular ejection fraction was 23.5 ± 5.8%, VO₂ max was 10.3 ± 2.3 mL/kg/min, cardiac index was 2.3 ± 0.5 L/min/m² , and N-terminal pro-brain natriuretic peptide (NT-pro-BNP) was 4943.0 ± 5326.8 pg/mL. After a mean follow-up of 17.1 ± 4.4 months, no deaths were observed, but NYHA class improved significantly with 56.8% in NYHA II, 40.5% in NYHA III, and 2.7% in NYHA IIIB (P < 0.001). VO₂ max and 6 min walk test (6MWT) increased, whereas pulmonary systolic blood pressure, E/E', VE/VCO₂ slope, and NT-pro-BNP decreased. At right heart catheterization performed after 1 year of follow-up, cardiac index and pulmonary vascular resistance remained stable, while a decrease in systolic pulmonary artery pressure and pulmonary capillary wedge pressure is observed. Furosemide dosage decrease from 102.7 ± 69.4 to 78.7 ± 66.3 mg (P = 0.040). PF decreased from 3.35 ± 1.0 at baseline to 1.57 ± 1.3 at the end of follow-up (P < 0.001), with a reduction in all PF domains.

CONCLUSIONS

Our study showed a rapid improvement in PF in HT waiting list patients treated with sacubitril/valsartan. The improvement in all PF domains was paralleled by VO₂ and 6MWT increase and together with an NT-pro-BNP reduction constant over the follow-up.

Prevalence and predictors of frailty in a high-income developing country: A cross-sectional study

Background: Frailty is a state of vulnerability and a decreased physiological response to stressors. As the population ages, the prevalence of frailty is expected to increase. Thus, identifying tools and resources that efficiently predict frailty among the Saudi population is important. We aimed to describe the prevalence and predictors of frailty among Saudi patients referred for cardiac stress testing with nuclear imaging. Methods: We included 876 patients (mean age 60.3 ± 11 years, women 48%) who underwent clinically indicated cardiac nuclear stress testing between January and October 2016. Fried Clinical Frailty Scale was used to assess frailty. Patients were considered frail if they had a score of four or higher. Multivariate adjusted logistic regression models were used to determine the independent predictors of elderly frail patients. Results: In this cohort, the median age of the included patients was 61 years, and the prevalence of frailty was 40%. The frail patients were older, more frequently women, and had a higher body mass index. Additionally, frailty was associated with a higher prevalence of cardiovascular risk factors: hypertension (85% vs. 70%) and diabetes (75% vs. 60%). In a fully adjusted logistic regression model, women, hypertension, and obesity (BMI ≥ 30 kg/m²) were independent predictors of elderly frail patients. Conclusions: With the aging of the Saudi population, frailty prevalence is expected to increase. Elderly, obesity, hypertension, and female gender are risk factors of frailty. Interventions to reduce frailty should be focused on this high-risk population.

Frailty in patients with heart failure

The importance of frailty in heart failure (HF) patients has been increasingly recognized because of its high prevalence and its significantly adverse impact on prognosis and quality of life. Due to the impact of frailty on both prognosis and treatment of HF patients, all patients with HF, regardless of their chronological age, should be evaluated for the presence of, or the risk for developing frailty. However, although several instruments are available, there is still no consensus as to which is the best method to assess frailty in patients with HF. Therefore, a validated and easy to apply instrument to assess frailty in HF patients in daily practice is warranted.

Influenza Vaccine in Heart Failure

BACKGROUND

Influenza infection is a serious event for patients with heart failure (HF). Little knowledge exists about the association between influenza vaccination and outcome in patients with HF. This study sought to determine whether influenza vaccination is associated with improved long-term survival in patients with newly diagnosed HF.

METHODS

We performed a nationwide cohort study including all patients who were >18 years of age and diagnosed with HF in Denmark in the period of January 1, 2003, to June 1, 2015 (n=134 048). We collected linked data using nationwide registries. Vaccination status, number, and frequency during follow-up were treated as time-varying covariates in time-dependent Cox regression.

RESULTS

Follow-up was 99.8% with a median follow-up time of 3.7 years (interquartile range, 1.7-6.8 years). The vaccination coverage of the study cohort ranged from 16% to 54% during the study period. In unadjusted analysis, receiving ≥1 vaccinations during follow-up was associated with a higher risk of death. After adjustment for inclusion date, comorbidities, medications, household income, and education level, receiving ≥1 vaccinations was associated with an 18% reduced risk of death (all-cause: hazard ratio, 0.82; 95% CI, 0.81-0.84; P<0.001; cardiovascular causes: hazard ratio, 0.82; 95% CI, 0.81-0.84; P<0.001). Annual vaccination, vaccination early in the year (September to October), and greater cumulative number of vaccinations were associated with larger reductions in the risk of death compared with intermittent vaccination.

CONCLUSIONS

In patients with HF, influenza vaccination was associated with a reduced risk of both all-cause and cardiovascular death after extensive adjustment for confounders. Frequent vaccination and vaccination earlier in the year were associated with larger reductions in the risk of death compared with intermittent and late vaccination.

sST2 Predicts Outcome in Chronic Heart Failure Beyond NT-proBNP and High-Sensitivity Troponin T

BACKGROUND

Soluble suppression of tumorigenesis-2 (sST2) is a biomarker related to inflammation and fibrosis.

OBJECTIVES

This study assessed the independent prognostic value of sST2 in chronic heart failure (HF).

METHODS

Individual patient data from studies that assessed sST2 for risk prediction in chronic HF, together with N-terminal pro-B-type natriuretic peptide (NT-proBNP) and high-sensitivity troponin T (hs-TnT), were retrieved.

RESULTS

A total of 4,268 patients were evaluated (median age 68 years, 75% males, 65% with ischemic HF, 87% with left ventricular ejection fraction [LVEF] <40%). NT-proBNP, hs-TnT, and sST2 were 1,360 ng/l (interquartile interval: 513 to 3,222 ng/l), 18 ng/l (interquartile interval: 9 to 33 ng/l), and 27 ng/l (interquartile interval: 20 to 39 ng/l), respectively. During a 2.4-year median follow-up, 1,319 patients (31%) experienced all-cause death (n = 932 [22%] for cardiovascular causes). Among the 4,118 patients (96%) with available data, 1,029 (24%) were hospitalized at least once for worsening HF over 2.2 years. The best sST2 cutoff for the prediction of all-cause and cardiovascular death and HF hospitalization was 28 ng/ml, with good performance at Kaplan-Meier analysis (log-rank: 117.6, 61.0, and 88.6, respectively; all p < 0.001). In a model that included age, sex, body mass index, ischemic etiology, LVEF, New York Heart Association functional class, glomerular filtration rate, HF medical therapy, NT-proBNP, and hs-TnT, the risk of all-cause death, cardiovascular death, and HF hospitalization increased by 26%, 25%, and 30%, respectively, per each doubling of sST2. sST2 retained its independent prognostic value across most population subgroups.

CONCLUSIONS

sST2 yielded strong, independent predictive value for all-cause and cardiovascular mortality, and HF hospitalization in chronic HF, and deserves consideration to be part of a multimarker panel together with NT-proBNP and hs-TnT.

Evaluating the convergent and discriminant validity of three versions of the frailty phenotype in heart failure: results from the FRAME-HF study

BACKGROUND

Frailty is an important predictive measure of mortality and rehospitalisation in people with heart failure. To date, there are no frailty instruments validated for use in people with heart failure.

AIM

The aim of this study was to evaluate the convergent and discriminant validity of three versions of the frailty phenotype in those with heart failure.

METHODS

A single site, prospective cohort study was undertaken among individuals with a confirmed diagnosis of heart failure. Frailty was assessed concurrently using three versions of the frailty phenotype: the original frailty phenotype and two modified versions; the Survey of Health, Ageing and Retirement in Europe frailty instrument (SHARE-FI) and the St Vincent's frailty instrument. Convergent and discriminant validity were assessed by reporting the correlations between each version and related heart failure subconstructs, and by evaluating the ability of each version to discriminate between normal and abnormal scores of other physical and psychosocial scales specific to heart failure-related subconstructs.

RESULTS

The New York Heart Association classes were moderately correlated with the St Vincent's frailty instrument (r=0.47, P⩽0.001), SHARE-FI (r=0.42, P⩽0.001) and the frailty phenotype (r=0.42, P⩽0.001). The SHARE-FI and the St Vincent's frailty instrument were both able to discriminate consistently between normal and abnormal scores in three out of five of the physical and psychosocial subconstructs that were assessed. The SHARE-FI was also able to discriminate between inpatients and outpatients who were classified as frail.

CONCLUSIONS

Both the SHARE-FI and the St Vincent's frailty instrument displayed good convergent and discriminant validity.

Mechanical Circulatory Support Device Utilization and Heart Transplant Waitlist Outcomes in Patients With Restrictive and Hypertrophic Cardiomyopathy

BACKGROUND

Patients with restrictive cardiomyopathy (RCM) and hypertrophic cardiomyopathy (HCM) generally are considered poor candidates for mechanical circulatory support devices (MCSDs) and often not able to be bridged mechanically to heart transplantation. This study characterized MCSD utilization and transplant waitlist outcomes in patients with RCM/HCM under the current allocation system and discusses changes in the era of the new donor allocation system.

METHODS AND RESULTS

Patients waitlisted from 2006 to 2016 in the United Network for Organ Sharing registry were stratified by RCM/HCM versus other diagnoses. MCSD utilization and waitlist duration were analyzed by propensity score models. Waitlist outcomes were assessed by cumulative incidence functions with competing events. Predictors of waitlist mortality or delisting for worsening status in patients with RCM/HCM were identified by proportional hazards model. Of 30 608 patients on the waitlist, 5.1% had RCM/HCM. Patients with RCM/HCM had 31 fewer waitlist days (P<0.01) and were ≈26% less likely to receive MCSD (P<0.01). Cumulative incidence of waitlist mortality was similar between cohorts; however, patients with RCM/HCM had higher incidence of heart transplantation. Predictors of waitlist mortality or delisting for worsening status in patients with RCM/HCM without MCSD support included estimated glomerular filtration rate <60 mL/min per 1.73 m², pulmonary capillary wedge pressure >20 mm Hg, inotrope use, and subjective frailty.

CONCLUSIONS

Patients with RCM/HCM are less likely to receive MCSD but have similar waitlist mortality and slightly higher incidence of transplantation compared with other patients. The United Network for Organ Sharing RCM/HCM risk model can help identify patients who are at high risk for clinical deterioration and in need of expedited heart transplantation.

Coexisting Frailty With Heart Failure

People over 65 years of age constitute over 80% of patients with heart failure (HF) and the incidence of HF is 10 per 1,000 in people aged above 65 years. Approximately 25% of older patients with HF exhibit evidence of frailty. Frail patients with cardiovascular disease (CVD) have a worse prognosis than non-frail patients, and frailty is an independent risk factor for incident HF among older people. Planning the treatment of individuals with HF and concomitant frailty, one should consider not only the limitations imposed by frailty syndrome (FS) but also those associated with the underlying heart disease. It needs to be emphasized that all patients with HF and concomitant FS require individualized treatment.

Muscle Mass and Mortality After Cardiac Transplantation

BACKGROUND

Frailty assessment is recommended to evaluate the candidacy of adults referred for orthotopic heart transplantation (OHT). Psoas muscle area (PMA) is an easily measured biomarker for frailty. There has yet to be a study examining the prognostic impact of PMA in OHT patients.

METHODS

In this retrospective study, preoperative and postoperative computed tomography (CT) scans were retrieved for adults transplanted between 2000 and 2015 at a tertiary care hospital. Psoas muscle area was measured on a single axial image. Outcomes of interest were all-cause mortality over 6 years and a composite of in-hospital mortality or major morbidity (prolonged ventilation, stroke, dialysis, mediastinitis, or reoperation).

RESULTS

Of 161 adult patients transplanted, 82 had at least 1 abdominal CT scan. At baseline, mean PMA was 25.7 ± 5.8 cm in men and 16.0 ± 3.6 cm in women, and decreased by 8% from the first to the last available CT scan. Adjusting for age, sex, body mass index, and cardiomyopathy etiology, every 1-cm increase in PMA was found to be associated with a 9% reduction in long-term mortality (hazard ratio, 0.91; 95% confidence interval [CI], 0.83-0.99; P = 0.031) and a 17% reduction in in-hospital mortality or major morbidity (odds ratio, 0.83; 95% CI, 0.72-0.96; P = 0.014). When PMA was smaller than the sex-specific median, the risk of mortality or major morbidity increased fourfold (odds ratio, 4.29; 95% CI, 1.19-15.46; P = 0.026).

CONCLUSIONS

Muscle mass is an independent predictor of mortality and major morbidity after OHT. Further research is needed to determine whether frail OHT patients with low PMA may benefit from muscle-building interventions to improve outcomes.

Abdominal skeletal muscle mass as a predictor of mortality in Japanese patients undergoing left ventricular assist device implantation

Aims

We assessed preoperative muscle wasting in patients undergoing left ventricular assist device (LVAD) implantations using abdominal skeletal muscle images on computed tomography (CT) and explored the associations between the preoperative muscle wasting and clinical outcomes after LVAD implantation.

Methods and results

We retrospectively examined the records of 111 patients who underwent continuous‐flow LVAD implantations as bridge‐to‐transplant therapy from January 2010 to December 2016 at our institution. After 33 patients were excluded, the study cohort consisted of 78 individuals. CT images used to calculate the skeletal muscle index (SMI) at the third lumbar vertebra level were obtained before the LVAD implantation procedures. Patients were classified as having muscle wasting if their SMI fell into the lowest gender‐based tertile. The median SMI for the study patients was 37.6 cm²/m². The SMI cut‐off values for the lowest tertiles were 36.7 cm²/m² for men and 28.2 cm²/m² for women, resulting in 26 patients (33.3%) with muscle wasting in this study. During the mean follow‐up of 738 ± 379 days, there were 10 deaths (12.8% mortality). Seven of the 26 patients with muscle wasting (26.9%) died, and 3 of the 52 patients without muscle wasting (5.8%) died. The times to all‐cause mortality were significantly different between patients with and without muscle wasting (P = 0.0094). Muscle wasting was found to be associated with mortality in univariate and multivariate Cox analyses (hazard ratio: 4.32; 95% CI: 1.19–20.2).

Conclusions

Preoperative muscle wasting was associated with a higher mortality in patients with LVAD. Assessment of the abdominal skeletal muscle area on CT prior to LVAD implantation can help predict mortality.

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

Background

The response to cardiac resynchronization therapy (CRT) is an important element of the treatment of advanced heart failure, especially in the geriatric population. The aim of the study was to examine the impact of frailty syndrome on the response to treatment with CRT.

Methods

Two hundred and forty-six patients of 60 years or older (aged 73.35±6.95; 22.4% women) with an implanted CRT were included in this single-center prospective study. There was a 12-month follow-up. The Tilburg Frailty Indicator was used to determine frailty (5 or more points). The response to CRT was evaluated based on an analysis of clinical criteria.

Results

One hundred and sixty-nine of 246 (68.9%) patients were found to be clinical CRT responders. Frailty syndrome was recognized in 173 (70.32%). There were 63.0% responders in the frailty-affected group, whereas there were statistically more responders (79.5%) in the robust group (P=0.0116). In the logistic regression, frailty emerged as an independent predictor of the response to CRT (OR=0.81, 95% CI=0.71–0.92; P=0.0008). The area under the curve of the ROC curve for frailty in the responders to CRT was 0.62. The cut-off value for a designation of frailty was 6 (P=0.0014).

Conclusion

Frailty is a novel independent factor that can be used to predict the clinical response to CRT in the elderly population. Modifying the level of recognition in the Tilburg Frailty Indicator can improve the prediction of a response to CRT.

Heart Failure and Problems with Frailty Syndrome: Why it is Time to Care About Frailty Syndrome in Heart Failure

Frailty syndrome (FS) is an independent predictor of mortality in cardiovascular disease and is found in 15–74% of patients with heart failure (HF). The syndrome has a complex, multidimensional aetiology and contributes to adverse outcomes. Proper FS diagnosis and treatment determine prognosis and support the evaluation of treatment outcomes. Routine FS assessment for HF patients should be included in daily clinical practice as an important prognostic factor within a holistic process of diagnosis and treatment. Multidisciplinary team members, particularly nurses, play an important role in FS assessment in hospital and primary care settings, and in the home care environment. Raising awareness of concurrent FS in patients with HF patients and promoting targeted interventions may contribute to a decreased risk of adverse events, and a better prognosis and quality of life.

Frailty, body composition and the risk of mortality in incident hemodialysis patients: the Predictors of Arrhythmic and Cardiovascular Risk in End Stage Renal Disease study

Background

Frail obese community-dwelling older adults are at increased mortality risk. Among hemodialysis (HD) patients, frailty is common and associated with increased mortality risk; however, in dialysis, obesity is associated with decreased mortality risk. Whether the frail-obese phenotype is associated with increased mortality risk among HD patients remains unclear.

Methods

This study included 370 incident HD patients enrolled in the Predictors of Arrhythmic and Cardiovascular Risk in End Stage Renal Disease (PACE) study. We measured frailty using the Fried phenotype, general obesity [body mass index (BMI) ≥30 kg/m2] and abdominal obesity [waist:hip ratio (WHR) ≥median WHR] and estimated their associations with mortality.

Results

The mean age was 55 years, with 42% female, 73% African American, 57% diabetic and 52% frail. Frail HD patients had higher mean BMI (frail = 30.3 kg/m2, non-frail = 28.3 kg/m2; P = 0.02) and similar WHR (P = 0.8). Twenty-two percent were frail with general obesity and 27% were frail with abdominal obesity. Frailty was associated with 1.66-fold increased mortality risk [95% confidence interval (CI) 1.03-2.67]. BMI was associated with a decreased mortality risk [25.0-29.9 kg/m2 hazard ratio (HR) 0.53 (95% CI 0.31-0.93); ≥30 kg/m2 HR 0.34 (95% CI 0.19-0.62)]. Frailty was associated with elevated mortality risk among HD patients with general [HR 3.77 (95% CI 1.10-12.92)] and abdominal obesity [HR 2.38 (95% CI 1.17-4.82)]. Frailty was not associated with mortality among HD patients without general or abdominal obesity.

Conclusions

In adults initiating HD, frailty was associated with elevated mortality risk, even among the obese. Frail-obese HD patients may be a high-risk, often-overlooked population, as obesity is assumed to be protective. Measurement of frailty and obesity may facilitate risk stratification.

Skeletal muscle wasting in chronic heart failure

Patients suffering from chronic heart failure (CHF) show an increased prevalence (~20% in elderly CHF patients) of loss of muscle mass and muscle function (i.e. sarcopenia) compared with healthy elderly people. Sarcopenia, which can also occur in obese patients, is considered a strong predictor of frailty, disability, and mortality in older persons and is present in 5–13% of elderly persons aged 60–70 years and up to 50% of all octogenarians. In a CHF study, sarcopenia was associated with lower strength, reduced peak oxygen consumption (peak VO₂, 1173 ± 433 vs. 1622 ± 456 mL/min), and lower exercise time (7.7 ± 3.8 vs. 10.22 ± 3.0 min, both P < 0.001). Unfortunately, there are only very limited therapy options. Currently, the main intervention remains resistance exercise. Specialized nutritional support may aid the effects of resistance training. Testosterone has significant positive effects on muscle mass and function, and low endogenous testosterone has been described as an independent risk factor in CHF in a study with 618 men (hazard ratio 0.929, P = 0.042). However, the use of testosterone is controversial because of possible side effects. Selective androgen receptor modulators have been developed to overcome these side effects but are not yet available on the market. Further investigational drugs include growth hormone, insulin‐like growth factor 1, and several compounds that target the myostatin pathway. The continuing development of new treatment strategies and compounds for sarcopenia, muscle wasting regardless of CHF, and cardiac cachexia makes this a stimulating research area.

Frailty is independently associated with 1-year mortality after hospitalization for acute heart failure

INTRODUCTION

Frailty is a complex condition that results from the loss of physiological reserve across multiple systems. Its presence should be considered in the aging heart failure population, since it is an important predictor of death and institutionalization in the elderly.

METHODS AND RESULTS

In a prospective, observational and analytical single-center study of 100 elderly patients hospitalized for acute heart failure, we assessed the characteristics associated with an increased hospital and 1-year mortality. Frailty was evaluated with the Clinical Frailty Scale, and there was a significant association between its presence and 1-year mortality (RR = 2.03; 95% CI = 1.18-3.48; p = 0.014), although not with in-hospital mortality. After adjusting for probable confounders, it remained independently associated with 1-year mortality.

CONCLUSION

Frailty can be assessed with a simple bed-side scale and provides significant prognostic information in acute heart failure patients.

Prognostic Value of Frailty for Older Patients with Heart Failure: A Systematic Review and Meta-Analysis of Prospective Studies

OBJECTIVE

Numerous studies have investigated the prognostic role of frailty in elderly patients with heart failure (HF), but the limited size of the reported studies has resulted in continued uncertainty regarding its prognostic impact. The aim of this study was to integrate the findings of all available studies and estimate the impact of frailty on the prognosis of HF by performing a systematic review and meta-analysis.

METHODS

PubMed, Embase, Cochrane, and Web of Science databases were searched from inception to November 8th 2017 to identify eligible prospective studies. The Newcastle-Ottawa Scale (NOS) was used to evaluate study quality. The association between frailty and HF outcomes was reviewed. Overall hazard ratios (HRs) for the effects of frailty on all-cause mortality were pooled using a fixed-effect model and publication bias was evaluated using funnel plots.

RESULTS

A total of 10 studies involving 3033 elderly patients with HF were included in the systematic review and meta-analysis. All eligible studies indicated that frailty was of prognostic significance for HF patients. The HRs for the effects of frailty on all-cause mortality were 1.70 (95% confidence interval (CI): 1.41-2.04), based on the pooling of six studies that provided related data. However, publication bias was observed among the studies.

CONCLUSIONS

Frailty has a high prevalence among older patients with HF. Elderly HF patients with frailty have a poorer prognosis than those without frailty. Further studies are now required to implement the use of frailty assessment tools and explore effective interventions for frailty in older HF patients.

Recommendations of the Geriatric Cardiology Section of the Spanish Society of Cardiology for the Assessment of Frailty in Elderly Patients With Heart Disease

Frailty is an age-associated clinical syndrome characterized by a decrease in physiological reserve in situations of stress, constituting a state of vulnerability that involves a higher risk of adverse events. Its prevalence in Spain is high, especially in elderly individuals with comorbidity and chronic diseases. In cardiovascular disease, frailty is associated worse clinical outcomes and higher morbidity and mortality in all scenarios, in both acute and chronic settings, and could consequently influence diagnosis and treatment. However, frailty is often not addressed or included when planning the management of elderly patients with heart disease. In this article, we review the available scientific evidence and highlight the most appropriate scales for the measurement and assessment of frailty, some of which are more useful and have better predictive capacity than others, depending on the clinical context. We also underline the importance of properly identifying and assessing frailty in order to include it in the treatment and care plan that best suits each patient.

Muscle wasting and sarcopenia in heart failure and beyond: update 2017

Sarcopenia (loss of muscle mass and muscle function) is a strong predictor of frailty, disability and mortality in older persons and may also occur in obese subjects. The prevalence of sarcopenia is increased in patients suffering from chronic heart failure. However, there are currently few therapy options. The main intervention is resistance exercise, either alone or in combination with nutritional support, which seems to enhance the beneficial effects of training. Also, testosterone has been shown to increased muscle power and function; however, a possible limitation is the side effects of testosterone. Other investigational drugs include selective androgen receptor modulators, growth hormone, IGF‐1, compounds targeting myostatin signaling, which have their own set of side effects. There are abundant prospective targets for improving muscle function in the elderly with or without chronic heart failure, and the continuing development of new treatment strategies and compounds for sarcopenia and cardiac cachexia makes this field an exciting one.

Frailty syndrome and rehospitalizations in elderly heart failure patients

Background

Heart failure (HF) patients with frailty syndrome (FS) are at higher risk of falling, decreased mobility, ability to perform the basic activities of daily living, frequent hospitalizations, and death.

Aims

The purpose of this study was to evaluate the correlations between FS and hospital readmissions, and to assess which factors are associated with rehospitalizations.

Methods

The study included 330 patients with a mean age of 72.1 ± 7.9 years, diagnosed with HF. Frailty was measured using the Polish version of the Tilburg Frailty Indicator (TFI). Demographic, sociodemographic, and clinical data, such as the New York Heart Association (NYHA) functional class, ejection fraction (EF), number of rehospitalizations, and the medications taken, were obtained.

Results

Positive correlation was observed between the number of hospitalizations and FS. In the single-factor correlation analysis, treatment with diuretics, a higher NYHA class, and a lower left ventricular EF were predictors of a higher number of hospitalizations. Additionally, the physical and psychological components of the TFI, as well as the total TFI score, predisposed HF patients to more frequent hospitalizations.

Discussion

It seems that a deterioration of functional capabilities and an increase in symptom severity naturally lead to increased hospitalization frequency in HF. In the own study, regression analysis indicates that high NYHA classes and TFI social component scores are significant predictors of the number of hospitalizations in the studied group.

Conclusions

FS is highly prevalent among elderly HF patients. Higher frailty levels in elderly patients are a determinant of more frequent rehospitalizations in HF.

The Role of Nutritional Status in Elderly Patients with Heart Failure

Evidence indicates that malnutrition very frequently co-occurs with chronic heart failure (HF) and leads to a range of negative consequences. Studies show associations between malnutrition and wound healing disorders, an increased rate of postoperative complications, and mortality. In addition, considering the increasing age of patients with HF, a specific approach to their treatment is required. Guidelines proposed by the European Society of Cardiology (ESC) for treating acute and chronic HF refer to the need to monitor and prevent malnutrition in HF patients. However, the guidelines feature no strict nutritional recommendations for HF patients, who are at high nutritional risk as a group, nor do they offer any such recommendations for the poor nutritional status subgroup, for which high morbidity and mortality rates have been observed. In the context of multidisciplinary healthcare, recommended by the ESC and proven by research to offer multifaceted benefits, nutritional status should be systematically assessed in HF patients. Malnutrition has become a challenge within healthcare systems and day-to-day clinical practice, especially in developed countries, where it affects the course of disease and patients' prognosis.

Family Help With Medication Management: A Predictive Marker for Early Readmission

OBJECTIVES

To identify aspects of medication management that are associated with a greater risk of hospital readmission.

PATIENTS AND METHODS

We conducted a prospective cohort study, with a thorough medication history and reconciliation performed at admission and discharge. Patients 18 years or older (N=258) were prospectively enrolled on admission to a cardiology service at a tertiary care hospital from September 1, 2011, through July 31, 2012. All patients received their hospital and outpatient care within our institution, which minimized loss to follow-up. Readmission rates within 30 days and 6 months after discharge were recorded and used to investigate associations with specific characteristics related to medication regimen and management. Nominal logistic fit tests were used to establish associations with risk factors.

RESULTS

A higher risk of readmission within 30 days after discharge was seen with heart failure diagnosis (P=.003) and with increased severity of comorbid conditions based on Charlson score (P=.02). Patients whose family managed their medications entirely had a higher risk of readmission at 30 days (odds ratio, 2.92; 95% CI, 1.25-5.6; P=.01) and at 6 months (odds ratio, 3.54; 95% CI, 1.70-7.65; P<.001). These findings were independent of the presence of heart failure.

CONCLUSION

Patients requiring family member support with medication management should be considered at increased risk for readmission. Increased focus on these patients at discharge may help decrease readmissions.

Prospective Assessment of Frailty Using the Fried Criteria in Patients Undergoing Left Ventricular Assist Device Therapy

Frail patients are more prone to adverse events after cardiac surgery, particularly after implantation of left ventricular assist devices. Thus, frailty assessment may help identify patients unlikely to benefit from left ventricular assist device therapy. The purpose was to establish a suitable measure of frailty in adults with end-stage heart failure. In a prospective cohort of 75 patients (age 58 ± 12 years) with end-stage heart failure, we assessed the association between frailty (5-component Fried criteria) and the composite primary outcome of inpatient mortality or prolonged length of stay, as well as extubation status, time on ventilator, discharge status, and long-term mortality. Fried frailty criteria were met in 44 (59%) patients, but there was no association with the primary outcome (p = 0.10). However, an abridged set of 3 criteria (exhaustion, inactivity, and grip strength) was predictive of the primary outcome (odds ratio 2.9, 95% confidence interval 1.1 to 7.4), and of time to extubation and time to discharge. In patients with advanced heart failure, the 5-component Fried criteria may not be optimally sensitive to clinical differences. In conclusion, an abridged set of 3 frailty criteria was predictive of the primary outcome and several secondary outcomes, and may therefore be a clinically useful tool in this population.