Heart failure and frailty in older adults: The nexus of care complexity

Multimorbidity frailty index and clinical outcomes among 42,989 older heart failure patients directly discharged from emergency departments: A nationwide retrospective cohort study

AIMS

Frailty, a common and clinically significant condition in older adults with heart failure (HF), is often overlooked in emergency department (ED) settings. This study aims to evaluate the impact of frailty on clinical outcomes in older adults directly discharged from the ED due to HF.

METHODS AND RESULTS

This retrospective cohort study used data from Taiwan's National Health Insurance (NHI) database, identifying older adults (≥65 years) discharged from the ED due to HF between 2017 and 2021. Frailty was assessed using a 38-item multimorbidity frailty index (mFI) derived from ICD-10-CM codes, stratifying patients into fit, mild-to-moderately frail, and severely frail. Outcomes included all-cause mortality, all-cause readmissions, and HF-related readmissions. Cox regression and Fine and Gray models estimated the impact of frailty on these outcomes. Among 42,989 older HF patients (mean age 80.7 ± 8.2 years, 55.5 % female), 57.8 % were frail (46.4 % mild-to-moderately frail and 11.4 % severely frail). Six-month mortality rates were 12.0 % in fit, 16.0 % in mild-to-moderately frail, and 19.4 % in severely frail patients. Readmission rates showed similar patterns. The severely frail group had higher risks of mortality (aHR 1.44, 95 % CI 1.33-1.55), all-cause readmissions (sHR 1.69, 95 % CI 1.62-1.76), and HF-related readmissions (sHR 1.59, 95 % CI 1.48-1.71).

CONCLUSION

Frailty is prevalent among older adults directly discharged from the ED due to HF and significantly elevates risks of mortality and readmissions. These findings highlight the need for frailty assessment in ED settings for older HF patients to optimize care planning, and improve outcomes.

The burden of frailty in heart failure: Prevalence, impacts on clinical outcomes and the role of heart failure medications

BACKGROUND

Frailty often coexists with heart failure (HF), which significantly aggravates the clinical outcomes of older adults. However, studies investigating the interplay between frailty and HF in older adults are scarce. We aimed to assess the prevalence of frailty using the cumulative deficit approach and evaluate the impacts of frailty on health utilization, use of HF-related medications and adverse clinical outcomes (all-cause mortality, all-cause readmissions and HF readmissions) among older HF patients.

METHODS

A total of 38 843 newly admitted HF patients were identified from Taiwan's National Health Insurance Research Database and categorized into three frailty subgroups (fit, mild frailty and severe frailty) based on the multimorbidity frailty index. Cox regression models and Fine and Gray subdistribution hazard models were used to estimate the impacts of frailty on clinical outcomes at 1 and 2 years of follow-up. Generalized estimating equation models were further conducted to evaluate the associations between longitudinal and time-varying use of HF-related medications and clinical outcomes among distinct frailty subgroups.

RESULTS

Of 38 843 older HF patients (mean age 80.4 ± 8.5 years, 52.3% females) identified, 68.3% were categorized as frail (47.5% of mild frailty and 20.8% of severe frailty). The median number of readmissions (fit: 1 [inter-quartile range-IQR 2], mild frailty: 1 [IQR 2] and severe frailty: 2 [IQR 3]) increased with the severity of frailty. Only 27.3% of HF patients died of cardiovascular diseases regardless of their frailty status. Compared with the fit group, the severe frailty group was associated with increased risk of all-cause mortality (adjusted hazard ratio 1.16, 95% confidence interval [CI] 1.11-1.21), all-cause readmissions (subdistributional hazard ratio (sHR) 1.21, 95% CI 1.16-1.25) and HF-related readmissions (sHR 1.14, 95% CI 1.09-1.20) at 2 years of follow-up. Those who used triple or more HF-related medications were at lower risk for all-cause readmissions (adjusted odds ratio [aOR] 0.49, 95% CI 0.44-0.54) and HF-related readmissions (aOR 0.42, 95% CI 0.37-0.47) at 2 years of follow-up even in the severe frailty group.

CONCLUSIONS

Frailty is highly prevalent and associated with increased risk of all-cause mortality, all-cause readmissions and HF readmissions among older HF patients. Those who were using triple or more HF-related medications were at lower risk of adverse clinical outcomes across distinct frailty subgroups. Further studies are needed to optimize the treatment strategies for older HF patients with distinct frailty status.