Characterizing Sex Differences in Physical Frailty Phenotypes in Heart Failure

Background and design of the Physical Frailty and Symptom Monitoring and Management Behaviors in Heart Failure (PRISM-HF) study: A mixed methods study

Background

Many adults with heart failure (HF) are physically frail and have worse outcomes. While the biological profile of physical frailty in HF has been examined, the behavioral profile remains unstudied. Physical frailty may impact self-care behaviors, particularly symptom monitoring and management (SMM), which in turn results in adverse outcomes. This paper describes the background and design of a study that addresses this knowledge gap, entitled "Physical Frailty and Symptom Monitoring and Management Behaviors in Heart Failure" (PRISM-HF).

Study design and methods

PRISM-HF is a sequential mixed methods study where in Phase 1, we collect quantitative data from a sex-balanced sample of 120 adults with HF, and in Phase 2, we collect qualitative data from ∼32-40 adults from this sample, aiming to: (1) quantify associations among physical frailty, SMM behaviors, and outcomes; (2) describe the experience of SMM behaviors for physically frail and non-physically frail adults with HF; and (3) identify the SMM behavioral needs of physically frail and non-physically frail adults with HF. At baseline, we measure symptoms, SMM behaviors, and physical frailty and collect clinical events at 6-months. We will use generalized linear modeling and survival analysis in Aim 1, directed content analysis in Aim 2, and triangulation analyses using an informational matrix in Aim 3.

Conclusions

This innovative study will investigate the behavioral underpinnings of physical frailty in HF, incorporate the patient's perspective of SMM behaviors in the context of physical frailty, and identify possible explanations for the effect of physical frailty on outcomes.

Plasma proteomic biomarkers of physical frailty in heart failure: a propensity score matched discovery-based pilot study

BACKGROUND

Physical frailty is highly prevalent in heart failure (HF), but we lack an understanding of the underlying pathophysiology. Proteomic evaluation of plasma samples may elucidate potential mechanisms and biomarkers of physical frailty in HF.

OBJECTIVES

We aimed to identify plasma proteomic biomarkers that are differentially expressed between physically frail and non-physically frail adults with HF.

METHODS

This was a secondary analysis of a subset of data and plasma samples from a study of frailty among patients with New York Heart Association (NYHA) Functional Classification I-IV HF. Physical frailty was measured using the Frailty Phenotype Criteria. Propensity score matching was used to match pairs of physically frail (n = 20) vs. non-physically frail (n = 20) patients on clinical characteristics. Plasma samples were processed using a sensitive liquid chromatography mass spectrometry platform, utilizing a multiplexed tandem mass tag-labeled quantitative proteomics approach. Differentially expressed proteins were quantified individually using paired t tests with associated log fold change of 0.3 and Fisher's combined p values.

RESULTS

The sample (n = 40) was 62.8 ± 16.9 years old, 58% female, and 55% NYHA Class III/IV. Proteomic analysis revealed 7 proteins differentially expressed using full differential criteria: matrix metalloproteinase-14 was downregulated in frailty, and copine-1, low affinity immunoglobulin gamma Fc region receptor III-A and III-B, probable non-functional immunoglobulin kappa variable 2D-24, glutathione S-transferase Mu 1, and argininosuccinate lyase were upregulated in frailty.

CONCLUSIONS

Proteomic biomarkers related to the immune system, stress response, and detoxification were differentially expressed between physically frail and non-physically frail adults with HF.

Sedentary lifestyle and physical inactivity: A mutual interplay with early and overt frailty

AIMS

In recent years medical science and research are increasingly directed towards a holistic approach that considers health as global well-being rather than solely as the absence of disease. In this framework, lifestyle interventions and, in particular, physical exercise, are of crucial importance in prevention and treatment. Therefore, the purpose of this study is to describe this mutual interplay between physical behaviours, sarcopenia, and frailty, as well as to illustrate the role of structured exercise training in aging and disease.

DATA SYNTHESIS

Physical activity and exercise training are determinants of lifelong global wellness and healthy aging. On the contrary, sedentary behaviour and physical inactivity are strictly linked to frailty and pre-frailty, both in adults and the elderly, with or without chronic diseases. On the other hand, the presence of pathological conditions is associated with a more inactive and sedentary behaviour. The co-presence of these factors is characterized by a mutual causal exchange in which they are imbricated in a continuous mechanistic interplay that involves inflammation, sarcopenia, osteopenia, functional impairment and many other pathophysiological aspects that rapidly can lead to a status of frailty.

CONCLUSION

A sedentary lifestyle and physical inactivity critically affect alterations in body composition and loss in functional capacity, typically linked to aging and accelerated by chronic diseases. However, physical activity and exercise can counteract the onset of pre-frailty and frailty by conferring beneficial effects on the individual's overall well-being.

Sex differences in the impact of frailty on patients with heart failure: A retrospective cohort study

AIMS

Limited literature shows the existence of sex differences in the long-term prognosis of heart failure (HF) patients with frailty. In this study, whether sex differences exist in the impact of frailty on death from cardiovascular causes in patients with HF was investigated by conducting a retrospective cohort study.

METHODS AND RESULTS

Data from the National Health and Nutrition Examination Survey (NHANES) study (2009-2018) were used to conduct a retrospective cohort study of 958 participants with HF. Patients were grouped based on sex and frailty index (FI). The relationship between death from cardiovascular causes and baseline frailty was assessed by Cox proportional hazard analysis and the Kaplan-Meier (K-M) plot. The study population had an age of 67.3 ± 12.3. Among them, around 54.5% were male. A median follow-up of 3.6 years was performed. After that, females who died from cardiovascular causes exhibited higher baseline FI values, while males did not show this trend (P < 0.05; P = 0.1253). Cox regression analysis demonstrated a significant association between FI and cardiovascular mortality in females (most frail: hazard ratio (HR) = 3.65, 95% confidence interval (CI): 1.07 ~ 12.39, P < 0.05; per 1-unit increase in FI: HR = 1.78, 95% CI: 1.33 ~ 2.39, P < 0.001). A dose-response association between FI and cardiovascular mortality was presented by restricted cubic splines.

CONCLUSIONS

Frailty is related to an increased risk of cardiovascular mortality in HF patients, particularly female patients.

Assessment of Frailty Among Older Adults in the Physical Activity Daily Trial

Frailty is common among cardiac patients; however, frailty assessment data from patients with peripheral arterial disease (PAD) are limited. The purpose of this observational study was to identify the prevalence and factors related to frailty in addition to unique frailty marker groupings in a cohort of sedentary adults with PAD. We grouped three PAD-relevant frailty characteristics using Fried's frailty phenotype -1) exhaustion, (2) weakness, and (3) slowness-and observed the prevalence of pre-frailty (1-2 characteristics) and frailty (3 characteristics) in the PAD cohort. Of the 106 participants, 34.9% were robust/non-frail, 53.8% were pre-frail, and 2.8% were frail. Exhaustion (33.3%) was the most occurring characteristic followed by weakness (20.0%) and slowness (5.0%). The grouping of weakness + slowness (10.0%) was the most prevalent followed by exhaustion + weakness (8.3%) and exhaustion + slowness (5.0%). Among pre-frail participants, ankle brachial index was correlated with a reduction in gait speed.

Sex and Gender-related Disparities in Clinical Characteristics and Outcomes in Heart Transplantation

PURPOSE OF REVIEW

Limited research has been conducted on sex disparities in heart transplant (HT). The aim of this review is to analyse the available evidence on the influence of sex and gender-related determinants in the entire HT process, as well as to identify areas for further investigation.

RECENT FINDINGS

Although women make up half of the population affected by heart failure and related mortality, they account for less than a third of HT recipients. Reasons for this inequality include differences in disease course, psychosocial factors, concerns about allosensitisation, and selection or referral bias in female patients. Women are more often listed for HT due to non-ischaemic cardiomyopathy and have a lower burden of cardiovascular risk factors. Although long-term prognosis appears to be similar for both sexes, there are significant disparities in post-HT morbidity and causes of mortality (noting a higher incidence of rejection in women and of malignancy and cardiac allograft vasculopathy in men). Additional research is required to gain a better understanding of the reasons behind gender disparities in eligibility and outcomes following HT. This would enable the fair allocation of resources and enhance patient care.

Sympathetic dysfunction is associated with worse fatigue and early and subtle symptoms in heart failure: an exploratory sex-stratified analysis

AIMS

Physical symptoms impact patients with heart failure (HF) despite treatment advancements; however, our understanding of the pathogenic mechanisms underlying HF symptoms remains limited, including sex differences therein. The objective of this study was to quantify associations between sympathetic markers [norepinephrine (NE) and 3,4-dihydroxyphenylglycol (DHPG)] and physical symptoms in patients with HF and to explore sex differences in these associations.

METHODS AND RESULTS

We performed a secondary analysis of combined data from two studies: outpatients with HF (n = 111), and patients prior to left ventricular assist device implantation (n = 38). Physical symptoms were measured with the Heart Failure Somatic Perception Scale (HFSPS) dyspnoea and early/subtle symptom subscales and the Functional Assessment in Chronic Illness Therapy Fatigue Scale (FACIT-F) to capture dyspnoea, early symptoms of decompensation, and fatigue. Norepinephrine and DHPG were measured with high-performance liquid chromatography with electrochemical detection. Multivariate linear regression was used to quantify associations between symptoms and sympathetic markers. The sample (n = 149) was 60.8 ± 15.7 years, 41% women, and 71% non-ischaemic aetiology. Increased plasma NE and NE:DHPG ratio were associated with worse FACIT-F scores (P = 0.043 and P = 0.013, respectively). Increased plasma NE:DHPG ratio was associated with worse HFSPS early/subtle symptoms (P = 0.025). In sex-stratified analyses, increased NE:DHPG ratio was associated with worse FACIT-F scores (P = 0.011) and HFSPS early/subtle scores (P = 0.022) among women but not men.

CONCLUSION

In patients with HF, sympathetic dysfunction is associated with worse fatigue and early/subtle physical symptoms with associations stronger in women than men.

Sex-related similarities and differences in responses to heart failure therapies

Although sex-related differences in the epidemiology, risk factors, clinical characteristics and outcomes of heart failure are well known, investigations in the past decade have shed light on an often overlooked aspect of heart failure: the influence of sex on treatment response. Sex-related differences in anatomy, physiology, pharmacokinetics, pharmacodynamics and psychosocial factors might influence the response to pharmacological agents, device therapy and cardiac rehabilitation in patients with heart failure. In this Review, we discuss the similarities between men and women in their response to heart failure therapies, as well as the sex-related differences in treatment benefits, dose-response relationships, and tolerability and safety of guideline-directed medical therapy, device therapy and cardiac rehabilitation. We provide insights into the unique challenges faced by men and women with heart failure, highlight potential avenues for tailored therapeutic approaches and call for sex-specific evaluation of treatment efficacy and safety in future research.

Frailty, Sarcopenia, Cachexia, and Malnutrition in Heart Failure

With global aging, the number of patients with heart failure has increased markedly. Heart failure is a complex condition intricately associated with aging, organ damage, frailty, and cognitive decline, resulting in a poor prognosis. The relationship among frailty, sarcopenia, cachexia, malnutrition, and heart failure has recently received considerable attention. Although these conditions are distinct, they often exhibit a remarkably close relationship. Overlapping diagnostic criteria have been observed in the recently proposed guidelines and position statements, suggesting that several of these conditions may coexist in patients with heart failure. Therefore, a comprehensive understanding of these conditions is essential, and interventions must not only target these conditions individually, but also provide comprehensive management strategies. This review article provides an overview of the epidemiology, diagnostic methods, overlap, and prognosis of frailty, sarcopenia, cachexia, and malnutrition in patients with heart failure, incorporating insights from the FRAGILE-HF study data. Additionally, based on existing literature, this article discusses the impact of these conditions on the effectiveness of guideline-directed medical therapy for patients with heart failure. While recognizing these conditions early and promptly implementing interventions may be advantageous, further data, particularly from well-powered, large-scale, randomized controlled trials, are necessary to refine personalized treatment strategies for patients with heart failure.

ALM/BMI: A Clinically Superior Index for Identifying Skeletal Muscle Dysfunction in Patients With Heart Failure

BACKGROUND

Skeletal muscle wasting is critical in patients with heart failure (HF). Whereas prior studies have employed appendicular lean mass (ALM) normalized by height squared to identify low skeletal muscle mass, the potential of ALM normalized to body mass index (ALM/BMI) remains unexplored in patients with HF. In this study, we compared the use of 2 skeletal muscle mass indices in patients with HF to examine their sex-specific correlations with measures of physical capacity, quality of life, and daily physical activity.

METHODS AND RESULTS

A total of 111 patients with HF underwent dual x-ray absorptiometry, physical capacity tests, and accelerometry and answered a quality-of-life questionnaire. ALM normalized by height squared and ALM/BMI indices disagreed in classifying low muscle mass (Cohen's κ, -0.008 [95% CI, -0.094 to 0.177]; P=0.93). ALM/BMI correlated well with 6-minute walking distance in women and men (R=0.67 and 0.49; P<0.001), with maximal oxygen uptake in women and men (R=0.41 and 0.48; P<0.05), and with maximal muscle strength in women and men (R=0.54 and 0.43; P<0.01). Inversely, ALM normalized by height squared did not correlate significantly with 6-minute walking distance or maximal oxygen uptake and correlated with maximal muscle strength only in men (R=0.43; P<0.001). Only ALM/BMI allowed for identification of a low-muscle-mass group characterized by poor quality of life (Minnesota Living With Heart Failure Questionnaire score of 33±21 versus 25±16; P=0.027) and less daily time spent in moderate to vigorous physical activity (8 [3-17] versus 15 [9-37] minutes; P<0.001).

CONCLUSIONS

ALM/BMI was superior for identifying clinically significant muscle dysfunction in both female and male patients with HF.

Hemoglobin is an independent predictor of improvement exercise tolerance in male patients with non-ischemic cardiomyopathy

Exercise intolerance is a symptom of chronic heart failure (CHF). The magnitude of exercise tolerance, as measured by peak oxygen uptake (peak VO2), is strongly associated with prognosis in patients with CHF. We aimed to evaluate the factors associated with improved exercise tolerance in patients with HF. In this prospective study, we recruited patients who were diagnosed with non-ischemic cardiomyopathy between September 2017 and September 2021. All patients underwent cardiopulmonary exercise testing at discharge and 6 months after enrollment. The patients were stratified according to whether peak VO2 was increased or not at 6 months. One hundred patients with a reduced left-ventricular ejection fraction (LVEF < 50%) were enrolled. Improvement of peak VO2 was observed in 74 patients. In male patients, hemoglobin level was higher in the increased peak VO2 group than in the non-increased group (15.0 ± 1.9 g/dL vs. 13.1 ± 2.1 g/dL; p < 0.01). Baseline hemoglobin level was positively correlated with the percentage change in peak VO2 (Spearman's r = 0.248, p = 0.040). Kaplan-Meier analysis demonstrated that adverse cardiac events were significantly less frequent in the increased peak VO2 group than in the non-increased group (log-rank test, p = 0.032). Multivariate logistic regression analysis identified hemoglobin level as an independent predictor of improved peak VO2 [odds ratio (OR) 1.60; 95% confidence interval (CI) 1.05-2.44; p = 0.027]. Baseline hemoglobin level is an independent predictor of improved peak VO2 in male patients with non-ischemic cardiomyopathy.

Impact of Frailty on Heart Failure Prognosis: Is Sex Relevant?

PURPOSE OF REVIEW

Heart failure (HF) is one of the most frequent causes of hospital admission in elderly patients, especially in women, who present a high prevalence of geriatric syndromes like frailty. Studies have suggested that frailty and its impact may also differ between males and females. Understanding how frailty may differently affect HF patients depending on sex is therefore imperative for providing personalized care. The aim of this review is to summarize the role of sex in the prognostic impact of frailty in HF patients.

RECENT FINDINGS

Numerous studies have identified frailty as a significant predictor of all-cause mortality and hospital readmissions. A recent study of elderly HF out-patients demonstrated that while women had a higher prevalence of frailty, it was an independent predictor of mortality and readmission only in men. Moreover, another study revealed that physical frailty was associated with time to first clinical event among men but not among women. These results raise the question about why frailty affects differently HF prognosis in men and women. Women with HF present a higher prevalence of frailty, especially when it is considered as physical decline. Nevertheless, frailty affects differently HF prognosis in men and women. Women with HF present lower mortality than men and frailty is related with prognosis only in men. The different severity of HF between men and women and other hormonal, psychosocial, and clinical factors might be involved in this fact.

The Reasons for the Low Uptake of New Antidiabetic Drugs with Cardiovascular Effects-A Family Doctor Perspective

Chronic diseases, such as type 2 diabetes (T2D), are difficult to manage because they demand continuous therapeutic review and monitoring. Beyond achieving the target HbA1c, new guidelines for the therapy of T2D have been introduced with the new groups of antidiabetics, glucagon-like peptide-1 receptor agonists (GLP-1ra) and sodium-glucose cotransporter-2 inhibitors (SGLT2-in). Despite new guidelines, clinical inertia, which can be caused by physicians, patients or the healthcare system, results in T2D not being effectively managed. This opinion paper explores the shift in T2D treatment, challenging assumptions and evidence-based recommendations, particularly for family physicians, considering the patient's overall situation in decision-making. We looked for the possible reasons for clinical inertia and the poor application of guidelines in the management of T2D. Guidelines for antidiabetic drugs should be more precise, providing case studies and clinical examples to define clinical contexts and contraindications. Knowledge communication can improve confidence and should include clear statements on areas of decision-making not supported by evidence. Precision medicine initiatives in diabetes aim to identify subcategories of T2D patients (including frail patients) using clustering techniques from data science applications, focusing on CV and poor treatment outcomes. Clear, unconditional recommendations for personalized T2D management may encourage drug prescription, especially for family physicians dealing with diverse patient contexts and clinical settings.

Incorporating reproductive system history data into cardiovascular nursing research to advance women's health

The lack of sex-specific variables, such as reproductive system history (RSH), in cardiovascular research studies is a missed opportunity to address the cardiovascular disease (CVD) burden, especially among women who face sex-specific risks of developing CVD. Collecting RSH data from women enrolled in research studies is an important step towards improving women's cardiovascular health. In this paper, we describe two approaches to collecting RSH in CVD research: extracting RSH from the medical record and participant self-report of RSH. We provide specific examples from our own research and address common data management and statistical analysis problems when dealing with RSH data in research.

Sex Differences in Cardiac and Clinical Phenotypes and Their Relation to Outcomes in Patients with Heart Failure

Biological sex is one of the major factors characterizing the heart failure (HF) patient phenotype. Understanding sex-related differences in HF is crucial to implement personalized care for HF patients with various phenotypes. There are sex differences in left ventricular (LV) remodeling patterns in the HF setting, namely, more likely concentric remodeling and diastolic dysfunction in women and eccentric remodeling and systolic dysfunction in men. Recently supra-normal EF (snLVEF) has been recognized as a risk of worse outcome. This pathology might be more relevant in female patients. The possible mechanism may be through coronary microvascular dysfunction and sympathetic nerve overactivation from the findings of previous studies. Further, estrogen deficit might play a significant role in this pathophysiology. The sex difference in body composition may also be related to the difference in LV remodeling and outcome. Lower implementation in guideline-directed medical therapy (GDMT) in female HFrEF patients might also be one of the factors related to sex differences in relation to outcomes. In this review, we will discuss the sex differences in cardiac and clinical phenotypes and their relation to outcomes in HF patients and further discuss how to provide appropriate treatment strategies for female patients.

Weak grip strength predicts higher unplanned healthcare utilization among patients with heart failure

AIMS

Frailty increases healthcare utilization and costs for patients with heart failure but is challenging to assess in clinical settings. Hand grip strength (GS) is a single-item measure of frailty yet lacks evidence as a potential screening tool to identify patients at risk of higher unplanned events and related healthcare costs. We examined the association of baseline and longitudinal GS measurements with healthcare utilization and costs among patients with advanced heart failure.

METHODS AND RESULTS

Between July 2017 and April 2019, we enrolled 251 patients with symptoms of advanced heart failure (New York Heart Association class III or IV) in a prospective cohort study in Singapore. We measured GS at baseline and every 4 months for 2 years and linked patients' survey data with their medical and billing records. We categorized patients as having weak GS if their GS measurement was below the 5th percentile of the age- and gender-specific normative GS values in Singapore. We assessed the association between baseline GS and healthcare utilization (unplanned and planned events and healthcare costs, total costs, and length of inpatient stay) over the next 2 years using regression models. We investigated the association between longitudinal 4-monthly GS assessments and the ensuing 4 months of healthcare utilization and costs using mixed-effects logistic and two-part regression models. At baseline, 22.5% of patients had weak GS. Baseline and longitudinal GS measurements were significantly associated with longer length of inpatient stay, greater likelihood of unplanned events, and higher related costs. Patients with weak GS had higher odds of an unplanned event occurring by 8 percentage points [95% confidence interval (CI) (0.01, 0.14), P = 0.026], incurred longer inpatient stays by 4 days [95% CI (1.97, 6.79), P = 0.003], and additional SG$ 4792 [US$ ~ 3594, 95% CI (1894, 7689), P = 0.014] in unplanned healthcare costs over the next 4 months.

CONCLUSIONS

GS is a simple tool to identify and monitor heart failure patients at risk of unplanned events, longer inpatient stays, and higher related healthcare costs. Findings support its routine use in clinical settings.

Gender differences in the association between physical frailty and life satisfaction among older adults in India

BACKGROUND

One of the sustainable development goals' (SDGs) primary goals (Goal 3) is to ensure healthy lives and promote well-being for persons of all ages. While extensive literature documents the link between physical frailty and low life satisfaction (LLS) among older adults, research of this nature is limited within low and middle-income countries including India. The purpose of this study was to examine the association between physical frailty and life satisfaction among community-dwelling older men and women in India.

METHODS

Data come from the 2017-18 wave 1 of the Longitudinal Ageing Study in India (LASI), with a sample of 30 390 individuals aged 60 and above (14 559 men and 15 831 women). Physical frailty was assessed using an adapted version of the frailty phenotype developed by Fried and colleagues. Ordered logistic regression models are employed to examine the association between physical frailty and life satisfaction.

RESULTS

The prevalence of frailty was higher in older women than men (32.2% vs. 27.5%). Nearly 30.4% of men and 33.8% of women reported having LLS. However, after adjusting for the selected confounders, women were less likely (adjusted odds ratio [aOR]: 0.92; CI: 0.87-0.97) to report LLS compared to men. The physically frail older adults were more likely (aOR: 1.40; CI: 1.27-1.55) to report LLS relative to their physically stronger counterparts. Moreover, we found that frail older men had higher odds of reporting LLS than non-frail older men (aOR: 1.25; CI: 1.09-1.43). Also, non-frail older women had lower odds of reporting LLS than non-frail older men (aOR: 0.80; CI: 0.67-0.95).

CONCLUSIONS

Findings of our study suggest that policies and programs to address later life well-being need to consider gender differences. Doing so would not only help identify older adults most at risk of LLS, but gender differentiated policies would help streamline health expenditures and costs typically relegated to assist all older adults without proper focus on the uniqueness of their social location.

Influence of Age, Gender, Frailty, and Body Mass Index on Serum IL-17A Levels in Mature Type 2 Diabetic Patients

BACKGROUND The cytokine IL-17A is emerging as a marker of chronic inflammation in cardio-metabolic conditions. This study aimed to identify relevant factors that in older primary care patients with type 2 diabetes (T2D) could influence serum IL-17A concentrations. The results have a potential to improve risk stratification and therapy options for these patients. MATERIAL AND METHODS The study was conducted during a period of 4 months, in 2020, in the south-eastern region of Croatia. Patients from primary health care, diagnosed with T2D (N=170, M: F 75: 95, ≥50 years old), were recruited at their visits. Those with malignant diseases, on chemotherapy or biological therapy, with amputated legs, or at hemodialysis, were excluded. The multinomial regression models were used to determine independent associations of the groups of variables, indicating sociodemographic and clinical characteristics of these patients, with increasing values (quartiles) of serum IL-17A. RESULTS The regression models indicated the frailty index and sex bias are the key modifying factors in associations of other variables with IL-17A serum values. CONCLUSIONS Sex bias and the existence of different frailty phenotypes could be the essential determining factors of the serum IL-17A levels in community-dwelling patients with T2D age 50 years and older. The results support the concept of T2D as a complex disorder.

Long-term trajectories of frailty phenotype in older cancer survivors: a nationally representative longitudinal cohort study

BACKGROUND

Frailty is a dynamic process associated with adverse health outcomes. However, little is known about the long-term trajectories of frailty in older cancer survivors.

OBJECTIVES

To describe the trajectories of frailty phenotype over time amongst older cancer survivors and examine the socio-demographic and health-related predictors of different trajectories.

DESIGN

Population-based longitudinal cohort study.

SETTING

Community-dwelling older adults in the United States.

SUBJECTS

1,763 older adults who were diagnosed with cancer from the National Health and Ageing Trends Study.

METHODS

Frailty was assessed by the Fried Frailty Phenotype. The group-based trajectory model was used to identify the trajectories of frailty. Multinomial logistic regression analyses were used to examine the socio-demographic and health-related predictors of different trajectories.

RESULTS

Three frailty trajectories were identified; 52.8% of older cancer survivors had a sustained low risk of frailty over time, 25.0% had a low frailty risk at baseline but the risk increased steadily, and 22.3% had a high frailty risk with a slight change in the observed period. Older cancer survivors were at a high-risk frailty trajectory if they were older, female, African American, had lower education status, had lower annual income, were underweight or obese, self-rated poorer health, had more chronic conditions and difficulties with activities of daily living (ADL), and had worse cognitive functions (P < 0.05).

CONCLUSIONS

Long-term frailty trajectories in older cancer survivors are heterogeneous. This study helps identify patients at high risk of sustained or deteriorating frailty and has the potential to inform targeted frailty management strategies addressing modifiable factors identified (e.g. body mass index, ADL).

Frailty and heart failure: State-of-the-art review

At least half of all patients with heart failure (HF) are affected by frailty, a syndrome that limits an individual ability to recover from acute stressors. While frailty affects up to 90% of patients with HF with preserved ejection fraction, it is also seen in ~30-60% of patients with HF with reduced ejection fraction, with ~26% higher prevalence in women compared with men. The relationship between frailty and HF is bidirectional, with both conditions exacerbating the other. Frailty is further complicated by a higher prevalence of sarcopenia (by ~20%) in HF patients compared with patients without HF, which negatively affects outcomes. Several frailty assessment methods have been employed historically including the Fried frailty phenotype and Rockwood Clinical Frailty Scale to classify HF patients based on the severity of frailty; however, a validated HF-specific frailty assessment tool does not currently exist. Frailty in HF is associated with a poor prognosis with a 1.5-fold to 2-fold higher risk of all-cause death and hospitalizations compared to non-frail patients. Frailty is also highly prevalent in patients with worsening HF, affecting >50% of patients hospitalized for HF. Such patients with multiple readmissions for decompensated HF have markedly poor outcomes compared to younger, non-frail cohorts, and it is hypothesized that it may be due to major physical and functional limitations that limit recovery from an acute episode of worsening HF, a care aspect that has not been addressed in HF guidelines. Frail patients are thought to confer less benefit from therapeutic interventions due to an increased risk of perceived harm, resulting in lower adherence to HF interventions, which may worsen outcomes. Multiple studies report that <40% of frail patients are on guideline-directed medical therapy for HF, of which most are on suboptimal doses of these medications. There is a lack of evidence generated from randomized trials in this incredibly vulnerable population, and most current practice is governed by post hoc analyses of trials, observational registry-based data and providers' clinical judgement. The current body of evidence suggests that the treatment effect of most guideline-based interventions, including medications, cardiac rehabilitation and device therapy, is consistent across all age groups and frailty subgroups and, in some cases, may be amplified in the older, more frail population. In this review, we discuss the characteristics, assessment tools, impact on prognosis and impact on therapeutic interventions of frailty in patients with HF.

Understanding and Investigating Sex-Based Differences in Heart Transplantation: A Call to Action

Women represent only about 25% of heart transplant recipients annually. Although the number of women living with advanced heart failure remains unknown, epidemiologic research suggests that more women should be receiving advanced heart failure therapies. Sex differences in risk factors, presentation, response to pharmacotherapy, and outcomes in heart failure have been well described. Yet, less is known about sex differences in heart transplant candidate selection, waitlist management, donor selection, perioperative considerations, and post-transplant management and outcomes. The purpose of this review was to summarize the existing published reports related to sex differences in heart transplantation, highlighting areas in which sex-based considerations are well described and supported by available evidence, and emphasizing topics that require further study.

Sex differences in the impact of physical frailty on outcomes in heart failure

BACKGROUND

Physical frailty is strongly related to adverse outcomes in heart failure (HF), and women are more likely to be physically frail than men; however, it is unknown if this sex difference affects outcomes.

OBJECTIVES

To determine if there are sex differences in the associations between physical frailty and health-related quality of life (HRQOL) and clinical outcomes in HF.

METHODS

We conducted a prospective study of adults with HF. Physical frailty was assessed using the Frailty Phenotype Criteria. HRQOL was assessed using the Minnesota Living with HF Questionnaire. One-year clinical events (all-cause death or cardiovascular hospitalization or emergency department visit) were ascertained. We used generalized linear modeling to quantify associations between physical frailty and HRQOL, and Cox proportional hazards modeling to quantify associations between physical frailty and clinical events, adjusting for Seattle HF Model scores.

RESULTS

The sample (n = 115) was 63.5 ± 15.7 years old and 49% women. Physical frailty was associated with significantly worse total HRQOL among women (p = 0.005) but not men (p = 0.141). Physical frailty was associated with worse physical HRQOL among both women (p < 0.001) and men (p = 0.043). There was a 46% higher clinical event risk for every one-point increase in physical frailty score among men (p = 0.047) but not women (p = 0.361).

CONCLUSIONS

Physical frailty is associated with worse overall HRQOL among women and higher clinical event risk among men, indicating a need to better understand contributors to sex-specific health differences associated with physical frailty in HF.

Comment on: Frailty in elderly patients with acute heart failure increases readmission

The study by Danika et al.¹ titled 'Frailty in elderly patients with acute heart failure increases readmission' is worth to read. The effect of frailty on readmission rates in elderly patients with acute heart failure is a significant and current issue that the authors have explored. Although the study offers insightful contributions to the field, I have found several areas that could use more elaboration and improvement to reinforce the research findings.

The association between frailty and anxiety: A systematic review

OBJECTIVES

Previous systematic reviews show a clear relationship between frailty and depression, however the association with anxiety is much less frequently explored. Previous single studies indicate evidence is mixed. We completed a systematic review and meta-analysis to identify the relationship between frailty and anxiety.

METHODS

We searched five electronic databases for observational studies in older people in community, care home and outpatient settings with any/no health conditions that measured the association between anxiety and frailty using validated measures. Studies were screened by one reviewer with 10% checked by a second reviewer. The Mixed Methods Appraisal Tool was used to assess study quality. We used meta-analysis to aggregate study findings, with subgroup analyses to explore heterogeneity.

RESULTS

Out of 1272 references, a total of 20 cross-sectional and 1 longitudinal studies were eligible. Older adults with frailty were substantially more likely to display anxiety symptoms than robust populations, across both dichotomous and continuous data sets (n = 10, OR = 3.48, 95% CI: 2.08, 5.81, p < 0.0001, I²  = 94%; N = 5, SMD = 3.13, 95% CI: 1.06, 5.21, I²  = 98%). Similarly, pre-frail older adults were more likely to have anxiety symptoms than robust older adults but to a lesser extent (N = 6, OR = 1.95, 95% CI: 1.41, 2.71, I²  = 63%; N = 3, SMD = 1.70, 95% CI: 0.01, 3.38, I²  = 98%).

CONCLUSIONS

There is a clear association between pre-frailty/frailty and anxiety in older adults. However, data are heterogeneous and primarily from cross-sectional studies so causality cannot be determined. Future research should evaluate the effectiveness of anxiety screening and treatments in frail older adults.

Candidate biomarkers of physical frailty in heart failure: an exploratory cross-sectional study

AIMS

Physical frailty is highly prevalent and predictive of worse outcomes in heart failure (HF). Candidate biomarker analysis may help in understanding the mechanisms underlying physical frailty in HF. We aimed to identify candidate biomarkers associated with physical frailty in HF using a multimarker strategy of distinct pathophysiological processes.

METHODS AND RESULTS

We collected data and plasma samples from 113 adults with New York Heart Association Functional Class I-IV HF. Physical frailty was measured with the Frailty Phenotype Criteria. Plasma biomarkers included: N-terminal pro-B-type natriuretic peptide, norepinephrine, dihydroxyphenylglycol, soluble tumour necrosis factor alpha receptor-1, adiponectin, insulin, glucose, insulin-like growth factor-1 (IGF-1), and myostatin. Comparative statistics and multivariate linear regression were used to test group differences and associations. The average age was 63.5 ± 15.7 years, half were women (48%), and most had a non-ischaemic aetiology of HF (73%). Physical frailty was identified in 42% and associated with female sex, higher body mass index and percent body fat, more comorbidities, and HF with preserved ejection fraction. Adjusting for Seattle HF Model projected survival score, comorbidities, body composition, and sex, physical frailty was associated with significantly lower plasma adiponectin [β ± standard error (SE) -0.28 ± 0.14, P = 0.047], IGF-1 (β ± SE -0.21 ± 0.10, P = 0.032), and myostatin (β ± SE -0.22 ± 0.09, P = 0.011). In sex-stratified analyses, IGF-1 and myostatin were significantly associated with physical frailty in men but not women.

CONCLUSION

We identified biomarkers involved in adipose tissue and skeletal muscle development, maintenance, and function that were associated with physical frailty in HF.

Frequency and Predictors of Falls Among Adults With Heart Failure: A Prospective Study

OBJECTIVE

Adults with heart failure (HF) may be at high risk for falling due to age, comorbidities and frailty; however, few studies have examined falls in HF. The purpose of this study was to quantify the frequency and predictors of falls over 1 year among adults with HF.

METHODS

We conducted a prospective study of adults with New York Heart Association (NYHA) functional class I-IV HF. After baseline assessment of physical frailty and clinical characteristics, participants self-reported falls every 3 months during 1 year. Comparative statistics were used to identify baseline differences between those who fell vs those who did not. A stepwise negative binomial regression model was used to identify predictors of fall rate over 1 year.

RESULTS

The sample (n = 111) was 63.4 ± 15.7 years old, 48% were women, 28% had HF with preserved ejection fraction, and 41% were frail. Over 1 year, 43 (39%) of participants reported at least 1 fall and 28 (25%) of participants reported 2+ falls. Among those who fell, 29 (67%) reported injurious falls. Those who fell had significantly higher body mass indexes and were more likely to have NYHA class III/IV, type 2 diabetes and HF with preserved ejection fraction and to meet slowness and physical exhaustion criteria than those who did not fall. The fall rate was elevated among those with type 2 diabetes and those meeting the slowness and physical exhaustion criteria for physical frailty.

CONCLUSIONS

Nearly 40% of adults with HF experienced a fall within 1 year. Screening for comorbidities, slowness and exhaustion may help to identify those at risk for a fall.

Sex differences in the impact of frailty in elderly outpatients with heart failure

Introduction

Frailty is common among patients with heart failure (HF). Our aim was to address the role of frailty in the management and prognosis of elderly men and women with HF.

Methods and results

Prospective multicenter registry that included 499 HF outpatients ≥75 years old. Mean age was 81.4 ± 4.3 years, and 193 (38%) were women. Compared with men, women were older (81.9 ± 4.3 vs. 81.0 ± 4.2 years, p = 0.03) and had higher left ventricular ejection fraction (46 vs. 40%, p < 0.001) and less ischemic heart disease (30 vs. 57%, p < 0.001). Women had a higher prevalence of frailty (22 vs. 10% with Clinical Frailty Scale, 34 vs. 15% with FRAIL, and 67% vs. 46% with the mobility visual scale, all p-values < 0.001) and other geriatric conditions (Barthel index ≤90: 14.9 vs. 6.2%, p = 0.003; malnutrition according to Mini Nutritional Assessment Short Formulary ≤11: 55% vs. 42%, p = 0.007; Pfeiffer cognitive test's errors: 1.6 ± 1.7 vs. 1.0 ± 1.6, p < 0.001; depression according to Yesavage test; p < 0.001) and lower comorbidity (Charlson index ≥4: 14.1% vs. 22.1%, p = 0.038). Women also showed worse self-reported quality of life (6.5 ± 2.1 vs. 6.9 ± 1.9, on a scale from 0 to 10, p = 0.012). In the univariate analysis, frailty was an independent predictor of mortality in men [Hazard ratio (HR) 3.18, 95% confidence interval (CI) 1.29–7.83, p = 0.012; HR 4.53, 95% CI 2.08–9.89, p < 0.001; and HR 2.61, 95% CI 1.23–5.43, p = 0.010, according to FRAIL, Clinical Frailty Scale, and visual mobility scale, respectively], but not in women. In the multivariable analysis, frailty identified by the visual mobility scale was an independent predictor of mortality (HR 1.95, 95% CI 1.04–3.67, p = 0.03) and mortality/readmission (HR 2.06, 95% CI 1.05–4.04, p = 0.03) in men.

Conclusions

In elderly outpatients with HF frailty is more common in women than in men. However, frailty is only associated with mortality in men.

Special Considerations in the Care of Women With Advanced Heart Failure

Advanced heart failure (AHF) is associated with increased morbidity and mortality, and greater healthcare utilization. Recognition requires a thorough clinical assessment and appropriate risk stratification. There are persisting inequities in the allocation of AHF therapies. Women are less likely to be referred for evaluation of candidacy for heart transplantation or left ventricular assist device despite facing a higher risk of AHF-related mortality. Sex-specific risk factors influence progression to advanced disease and should be considered when evaluating women for advanced therapies. The purpose of this review is to discuss the role of sex hormones on the pathophysiology of AHF, describe the clinical presentation, diagnostic evaluation and definitive therapies of AHF in women with special attention to pregnancy, lactation, contraception and menopause. Future studies are needed to address areas of equipoise in the care of women with AHF.

A Primer on Incorporating Sex as a Biological Variable into the Conduct and Reporting of Basic and Clinical Research Studies

The recent move to require sex as a biological variable (SABV), which includes gender, into the reporting of research published by the American Journal of Physiology - Heart and Circulatory Physiology follows a growing, and much-needed, trend by journals. Understandably, there is concern over how to do this without adding considerable work, especially if one's primary research focus is not on elucidating sex/gender differences. The purpose of this article is to provide additional guidance and examples on how to incorporate SABV into the conduct and reporting of basic and clinical research. Using examples from our research, which includes both studies focused and not focused on sex/gender differences, we offer suggestions for how to incorporate SABV into basic and clinical research studies.

Frailty Measures of Patient-reported Activity and Fatigue May Predict 1-year Outcomes in Ambulatory Advanced Heart Failure: A Report From the REVIVAL Registry

BACKGROUND

The Fried Frailty Phenotype predicts adverse outcomes in geriatric populations, but has not been well-studied in advanced heart failure (HF). The Registry Evaluation of Vital Information for Ventricular Assist Devices (VADs) in Ambulatory Life (REVIVAL) study prospectively collected frailty measures in patients with advanced HF to determine relevant assessments and their impact on clinical outcomes.

METHODS AND RESULTS

HF-Fried Frailty was defined by 5 baseline components (1 point each): (1) weakness: hand grip strength less than 25% of body weight; (2) slowness based on time to walk 15 feet; (3) weight loss of more than 10 lbs in the past year; (4) inactivity; and (5) exhaustion, both assessed by the Kansas City Cardiomyopathy Questionnaire. A score of 0 or 1 was deemed nonfrail, 2 prefrail, and 3 or greater was considered frail. The primary composite outcome was durable mechanical circulatory support implantation, cardiac transplant or death at 1 year. Event-free survival for each group was determined by the Kaplan-Meier method and the hazard of prefrailty and frailty were compared with nonfrailty with proportional hazards modeling. Among 345 patients with all 5 frailty domains assessed, frailty was present in 17%, prefrailty in 40%, and 43% were nonfrail, with 67% (n = 232) meeting the criteria based on inactivity and 54% (n = 186) for exhaustion. Frail patients had an increased risk of the primary composite outcome (unadjusted hazard ratio [HR] 2.82, 95% confidence interval [CI] 1.52-5.24; adjusted HR 3.41, 95% CI 1.79-6.52), as did prefrail patients (unadjusted HR 1.97, 95% CI 1.14-3.41; adjusted HR 2.11, 95% CI 1.21-3.66) compared with nonfrail patients, however, the predictive value of HF-Fried Frailty criteria was modest (Harrel's C-statistic of 0.603, P = .004).

CONCLUSIONS

The HF-Fried Frailty criteria had only modest predictive power in identifying ambulatory patients with advanced HF at high risk for durable mechanical circulatory support, transplant, or death within 1 year, driven primarily by assessments of inactivity and exhaustion. Focus on these patient-reported measures may better inform clinical trajectories in this population.

Sex Differences in Heart Failure

Heart failure (HF) continues to be a major contributor of morbidity and mortality for men and women alike, yet how the predisposition for, course and management of HF differ between men and women remains underexplored. Sex differences in traditional risk factors as well as sex-specific risk factors influence the prevalence and manifestation of HF in unique ways. The pathophysiology of HF differs between men and women and may explain sex-specific differences in clinical presentation and diagnosis. This in turn contributes to variation in response to both pharmacologic and device/surgical therapy. This review examines sex-specific differences in HF spanning prevalence, risk factors, pathophysiology, presentation, and therapies with a specific focus on highlighting gaps in knowledge with calls to action for future research efforts.