Frailty as a Risk Factor for Cardiovascular Versus Noncardiovascular Mortality in Older Men: Results From the MrOS Sleep (Outcomes of Sleep Disorders in Older Men) Study

The association between grip strength and carotid intima media thickness: A Mendelian randomization analysis of the Canadian Longitudinal Study on Aging

BACKGROUND

Several two-sample Mendelian randomization studies have reported discordant results concerning the association between grip strength and cardiovascular disease, possibly due to the number of instrumental variables used, pleiotropic bias, and/ or effect modification by age and sex.

METHODS

We conducted a sex- and age-stratified one-sample Mendelian randomization study in the Canadian Longitudinal Study on Aging. We investigated whether grip strength is associated with carotid intima media thickness (cIMT), a marker of vascular atherosclerosis event risk, using eighteen single nucleotide polymorphisms (SNP) identified as specifically associated with grip strength.

RESULTS

A total of 20,258 participants of self-reported European ancestry were included in the analytic sample. Our Mendelian randomization findings suggest a statistically significant association between grip strength and cIMT (MR coefficient of 0.02 (95% CI: 0.01, 0.04)). We found no statistically significant differences between sexes (p-value = 0.201), or age groups [(≤ 60 years old versus >60 years old); p-value = 0.421].

CONCLUSION

This study provides evidence that grip strength is inversely associated with cIMT. Our one-sample MR study design allowed us to demonstrate that there is no evidence of heterogeneity of effects according to age group or biological sex.

Frailty in Older Patients with Transthyretin Cardiac Amyloidosis

Background-Transthyretin cardiac amyloidosis (ATTR-CA) prevalence increases with age. The interplay between frailty and heart failure has been increasingly recognized. The objective of this study is to compare clinical, biological, and transthoracic echocardiography (TTE) characteristics of older ATTR-CA patients according to the G8 frailty screening tool. Methods-Patients over 75 years old with a confirmed diagnosis of ATTR-CA were included between January 2020 and April 2021. All patients underwent a routine blood test, TTE, and a functional assessment with a six-minute walking distance test (6MWD) or cardiopulmonary exercise testing (CPET), and the G8 score was calculated. Results-Fifty-two patients were included. Thirty-nine (75%) patients were frail and their mean NYHA stage was more severe (2.2 vs. 1.7; p = 0.004); 62% of them had a Gilmore stage of 2 or 3 (p = 0.05). Global left ventricular strain (GLS) was lower (-11.7% vs. -14.9%; p = 0.014) and the interventricular septum was thicker (18 ± 2 mm vs. 17 ± 2 mm; p = 0.033) in frail patients. There were no significant differences according to functional tests. Conclusion-The majority of older patients with ATTR-CA are frail according to the G8 score. They are more symptomatic and have an increased cardiac involvement and a poorer prognosis, requiring more personalized cardiac management.

The inverted U-shaped relationship between weight loss percentage and cardiovascular health scores

PURPOSE

Obesity is a significant risk factor for cardiovascular disease; however, the impact of weight loss on cardiovascular health (CVH) in individuals with specific obesity patterns remains incompletely understood. The objective of our study was to investigate the relationship weight loss percentage and CVH scores across individuals with various obesity patterns.

METHODS

Our study utilized data from the National Health and Nutrition Examination Survey conducted between 2007 and 2018, involving a total of 12,835 participants aged 16 years or older, to conduct a cross-sectional analysis. Multiple linear regression and multinomial logistic regression methods were used to assess the correlation between the weight loss percentage and the CVH scores. Additionally, restricted cubic spline analysis was employed to examine the nonlinear relationship between the two variables.

RESULTS

Compared to individuals with a weight loss percentage < 0%, participants with weight loss percentages of 0-5% and 5.1-10% showed improved CVH scores, with β values of 2.85 (95% CI 2.32-3.38) and 2.55 (95% CI 1.69-3.4), respectively. Regarding different obesity patterns, compared to participants with a weight loss percentage < 0%, participants with a weight loss percentage of 0-5% showed an increase in CVH scores in the normal weight and overweight/general obesity (OGO) groups, with β values of 1.45 (95% CI 0.7-2.19) and 1.22 (95% CI 0.46-1.97), respectively. Restricted cubic spline analysis revealed a significant inverted U-shaped relationship between the weight loss percentage and the CVH scores (with optimal CVH scores at 3%).

CONCLUSIONS

There was an inverted U-shaped relationship between weight loss percentage and CVH scores, with moderate weight loss (0-10%, optimal value of 3%) being associated with improved CVH scores, especially among individuals with OGO.

LEVEL V

Opinions of respected authorities, based on descriptive studies, narrative reviews, clinical experience, or reports of expert committees.

Frailty and Cardiovascular Mortality: A Narrative Review

PURPOSE OF REVIEW

The goal of the narrative review is to provide an overview of the epidemiology of frailty in cardiovascular disease and cardiovascular mortality and discuss applications of frailty in cardiovascular care of older adults.

RECENT FINDINGS

Frailty is highly prevalent in older adults with cardiovascular disease and is a robust, independent predictor of cardiovascular death. There is a growing interest in using frailty to inform management of cardiovascular disease either through pre- or post-treatment prognostication or by delineating treatment heterogeneity in which frailty serves to distinguish patients with differential harms or benefits from a given therapy. Frailty can enable more individualized treatment in older adults with cardiovascular disease. Future studies are needed to standardize frailty assessment across cardiovascular trials and enable implementation of frailty assessment in cardiovascular clinical practice.

The association between frailty and incident cardiovascular disease events in community-dwelling healthy older adults

Study objective

This study examined the association between frailty and incident cardiovascular disease (CVD) events, major adverse cardiovascular events (MACE), and CVD-related mortality.

Design

Longitudinal cohort study.

Setting

The ASPirin in Reducing Events in the Elderly (ASPREE) clinical trial in Australia and the United States.

Participants

19,114 community-dwelling older adults (median age 74.0 years; 56.4 % females).

Interventions

Pre-frailty and frailty were assessed using a modified Fried phenotype and a deficit accumulation Frailty Index (FI) at baseline.

Main outcome measures

CVD was defined as a composite of CVD death, non-fatal myocardial infarction, non-fatal stroke, and hospitalization for heart failure; MACE included all except heart failure. Cox proportional hazards regression was used to analyze the association between frailty and CVD outcomes over a median follow-up of 4.7 years.

Results

Baseline pre-frail and frail groups had a higher risk of incident CVD events (Hazard Ratio (HR): 1.31; 95 % Confidence Interval (CI): 1.14-1.50 for pre-frail and HR: 1.63; 95 % CI: 1.15-2.32 for frail) and MACE (pre-frail HR: 1.26; 95 % CI: 1.08-1.47 and frail HR: 1.51; 95 % CI: 1.00-2.29) than non-frail participants according to Fried phenotype after adjusting for traditional CVD risk factors. Effect sizes were similar or larger when frailty was assessed with FI; similar results for men and women.

Conclusion

Frailty increases the likelihood of developing CVD, including MACE, in community-dwelling older men and women without prior CVD events. Screening for frailty using Fried or FI method could help identify community-dwelling older adults without prior CVD events who are more likely to develop CVD, including MACE, and may facilitate targeted preventive measures to reduce their risk.

Body mass index, waist circumference and cardiovascular diseases in transitional ages (40 and 66 years)

BACKGROUND

There is lack of data on effect modification by age on the association between body mass index (BMI) or waist circumference (WC) and cardiovascular diseases (CVDs). We aimed to investigate the impact of BMI and WC on incident CVDs in individuals aged 40 and 66 years.

METHODS

Overall, 2 430 510 participants who underwent a national health screening for transitional ages provided by the Korean National Health Insurance Service between 2009 and 2012 were included. The adjusted hazard ratios and 95% confidence intervals for myocardial infarction (MI), ischaemic stroke and CVDs as a composite outcome of MI and ischaemic stroke were calculated using multivariable Cox proportional hazard regression analysis.

RESULTS

During a mean follow-up of 7.7 years, 24 884 MI and 29 415 ischaemic stroke events occurred. Among participants aged 40 years, there was a J-shaped association of BMI with incident CVDs, MI and ischaemic stroke with nadir at BMI 18.5-22.9 kg/m² (P for trend < 0.001 for all). Among those aged 66 years, there were significant U-shaped associations of BMI with CVDs and MI with nadir at a BMI of 23.0-24.9 kg/m² (P for trend 0.013 and 0.017, respectively). WC was linearly associated with all study outcomes in both age groups (P for trend <&nbsp;0.001). The impact of general and abdominal obesity on both study outcomes was more prominent in those aged 40 years than in those aged 66 years (P for interaction < 0.001).

CONCLUSIONS

To prevent cardiovascular risk, weight loss intervention should be cautiously implemented and individualized according to age. The maintenance of muscle mass may be essential in managing weight loss particularly in older population.

The impact of cardiovascular health and frailty on mortality for males and females across the life course

BACKGROUND

The effect of frailty and poor cardiovascular health on mortality for males and females is not fully elucidated. We investigated whether the combined burden of frailty and poor cardiovascular health is associated with all-cause and cardiovascular disease (CVD) mortality by sex and age.

METHODS

We analyzed data of 35,207 non-institutionalized US residents aged 20-85 years old (mean age [standard deviation]: 46.6 [16.7 years], 51.4% female, 70.8% White, 10.3% Black, 13.2% Hispanic) from the National Health and Nutrition Examination Survey (1999-2015). Cardiovascular health was measured with the American Heart Association's Life's Simple 7 score (LS7). A 33-item frailty index (FI) was constructed to exclude cardiovascular health deficits. We grouped the FI into 0.1 increments (non-frail: FI &lt; 0.10, very mildly frail: 0.1 ≤ FI &lt; 0.20, mildly frail: 0.20 ≤ FI &lt; 0.30, and moderately/severely frail: FI ≥ 0.30) and LS7 into tertiles (T1[poor] = 0-7, T2[intermediate] = 8-9, T3[ideal] = 10-14). All-cause and CVD mortality data were analyzed up to 16 years. All regression models were stratified by sex.

RESULTS

The average FI was 0.09 (SD 0.10); 29.6% were at least very mildly frail, and the average LS7 was 7.9 (2.3). Mortality from all-causes and CVD were 8.5% (4228/35,207) and 6.1% (2917/35,207), respectively. The median length of follow-up was 8.1 years. The combined burden of frailty and poor cardiovascular health on mortality risk varied according to age in males (FI*age interaction p = 0.01; LS7*age interaction p &lt; 0.001) but not in females. In females, poor FI and LS7 combined to predict all-cause and CVD mortality in a dose-response manner. All-cause and CVD mortality risk was greater for older males (60 and 70 years old) who were at least mildly frail and had intermediate cardiovascular health or worse (hazard ratio [lower/higher confidence interval ranges] range: all-cause mortality = 2.02-5.30 [1.20-4.04, 3.15-6.94]; CVD-related mortality = 2.22-7.16 [1.03-4.46, 4.49-11.50]) but not for younger males (30, 40, and 50 years old).

CONCLUSIONS

The combined burden of frailty and LS7 on mortality is similar across all ages in females. In males, this burden is greater among older people. Adding frailty to assessments of overall cardiovascular health may identify more individuals at risk for mortality and better inform decisions to implement preventative or treatment approaches.

Frailty and risks of all-cause and cause-specific death in community-dwelling adults: a systematic review and meta-analysis

Background

The associations of frailty with all-cause and cause-specific mortality remain unclear. Therefore, we performed this meta-analysis to fill this gap.

Methods

We searched the PubMed and Embase databases through June 2022. Prospective cohort studies or clinical trials examining frailty were evaluated, and the multiple adjusted risk estimates of all-cause and cause-specific mortality, such as death from cardiovascular disease (CVD), cancer, respiratory illness, dementia, infection, and coronavirus disease 2019 (COVID-19), were included. A random effects model was used to calculate the summary hazard ratio (HR).

Results

Fifty-eight studies were included for the qualitative systematic review, of which fifty-six studies were eligible for the quantitative meta-analysis, and the studies included a total of 1,852,951 individuals and more than 145,276 deaths. Compared with healthy adults, frail adults had a significantly higher risk of mortality from all causes (HR 2.40; 95% CI 2.17–2.65), CVD (HR 2.64; 95% CI 2.20–3.17), respiratory illness (HR 4.91; 95% CI 2.97–8.12), and cancer (HR 1.97; 95% CI 1.50–2.57). Similar results were found for the association between prefrail adults and mortality risk. In addition, based on the studies that have reported the HRs of the mortality risk per 0.1 and per 0.01 increase in the frailty index, we obtained consistent results.

Conclusions

The present study demonstrated that frailty was not only significantly related to an increased risk of all-cause mortality but was also a strong predictor of cause-specific mortality from CVD, cancer, and respiratory illness in community-dwelling adults. More studies are warranted to clarify the relationship between frailty and cause-specific mortality from dementia, infection, and COVID-19.

Trial registration

PROSPERO (CRD42021276021).

Supplementary Information

The online version contains supplementary material available at 10.1186/s12877-022-03404-w.

The relationship between body mass index and stroke: a systemic review and meta-analysis

BACKGROUND

Stroke is an acute cerebrovascular event closely related to brain tissue damage, and is one of the major causes of death and disability in worldwide. Various studies have reported the effects of body mass index (BMI) on the risk of stroke, but the results remain varied and these results have not been synthesized. Therefore, a meta-analysis was performed to evaluate the relationship between BMI and the risk of stroke.

OBJECTIVES

This systematic review was conducted to explore the relationship between BMI and the risk of stroke.

METHODS

PubMed, EMBASE, Web of Science and Cochrane Library, China Knowledge Resource Integrated Database (CNKI), WanFang Database, Chinese Biomedical Database (CBM), and CQVIP were comprehensively searched for studies exploring the relationship between BMI and stroke from inception to December 1, 2021.

RESULTS

This review included 24 studies involving 5,798,826 subjects. The results of meta-analysis showed that the pooled RR of stroke risk was 0.93 (95% confidence interval [CI] 0.82-1.06, I² = 88.8%, P = 0.29) for the underweight group. Higher BMI (overweight or obese group) was associated with an increased overall risk of stroke, with pooled RR values of 1.25 (95% CI 1.16-1.34, I² = 84.8%, P = 0.00) and 1.47 (95% CI: 1.02-2.11, I² = 99.4%, P = 0.04).

CONCLUSION

The risk of stroke was positively correlated with BMI, and the association was stronger in male and ischemic stroke. Lowering BMI can be used as a way to prevent stroke, and for people who are overweight or obese, lowering body weight can reduce the risk of stroke.

Elevated Risk Analysis Index (RAI) Frailty Scores Are Independently Associated with Adverse Outcomes in Lower Extremity Surgical Revascularizations Similarly Across Genders

INTRODUCTION

The Risk Analysis Index (RAI) frailty scoring system, developed in a predominantly male Veteran sample, has recently undergone revision and external validation to become the RAI-rev using a general surgical sample from the American College of Surgeons' National Surgical Quality Improvement Program (NSQIP) database. We set forth to evaluate the application of RAI-rev scoring to lower extremity surgical revascularization outcomes in the NSQIP database while verifying that similar associations with outcomes persist in this subset across genders.

METHODS

All elective cases in the NSQIP Targeted Lower Extremity Open (LEO) database recorded from 2015-2019 were paired with the NSQIP Participant User File using Case IDs. Groups were defined by EMR-recorded gender. Extended length of stay was defined as top quartile postoperative stays. Aggregate demographics, perioperative factors, and 30-day outcomes were compared between groups using unpaired t-test and Fisher's exact test. Adjusted odds-ratios (aOR) for each outcome were generated by applying a multivariate binary logistic regression model in IBM SPSS^TM for five-point RAI-rev score increments from 25-45 and a most-frail group with scores >45. Covariates included surgical indication, prior ipsilateral surgical revascularization versus percutaneous intervention, graft utilization, presence of dirty/infected wound, smoking, hypertension, diabetes, and steroid use. A non-frail group with RAI-rev scores <25 was utilized as the reference for generating adjusted odds ratios.

RESULTS

8,155 cases were recorded in the NSQIP LEO database from 2015-2019, including 2,498 (31%) performed in women who had slightly lower RAI-rev scores on average (22.1±5.8 vs 24.2±5.1; p=0.0001). Univariate trends demonstrated dose-dependent increases in frequency of most outcomes with rising frailty score ranges, with the most substantial changes over mortality (0.4% of non-frail to 14.7% most-frail), disposition to a skilled nursing facility (8% of non-frail to 27% most-frail), and extended length of stay (16% of non-frail to 44% most-frail). After adjusting for co-variates, patients with RAI-rev scores of 26-30 had aOR of 1.4 (95% CI: 1.2-1.6; p<0.001), 1.9 (95% CI: 1.6-2.2; p<0.001), and 2.4 (95% CI: 1.3-4.4; p<0.001) for extended stay, disposition to skilled nursing, and mortality respectively as compared to those with RAI-rev scores <25. Despite more non-significant aOR for women than men, trends were similar across genders in both univariate and multivariate analyses.

CONCLUSION

Our study is the first to find that outcomes other than mortality are significantly predicted by RAI-rev score ranges in lower extremity surgical revascularizations with similar associations regardless of gender. RAI-rev frailty scores >30 may help to identify frail patients at a higher risk of mortality, extended stay, and increased rehabilitation needs prior to lower extremity surgical revascularization to inform risk assessment and optimize patient recovery.

Frailty and cardiovascular mortality in more than 3 million US Veterans

AIMS

Frailty is associated with an increased risk of all-cause mortality and cardiovascular (CV) events. Limited data exist from the modern era of CV prevention on the relationship between frailty and CV mortality. We hypothesized that frailty is associated with an increased risk of CV mortality.

METHODS AND RESULTS

All US Veterans aged ≥65 years who were regular users of Veteran Affairs care from 2002 to 2017 were included. Frailty was defined using a 31-item previously validated frailty index, ranging from 0 to 1. The primary outcome was CV mortality with secondary analyses examining the relationship between frailty and CV events (myocardial infarction, stroke, revascularization). Survival analysis models were adjusted for age, sex, ethnicity, geographic region, smoking, hyperlipidaemia, statin use, and blood pressure medication use. There were 3 068 439 US Veterans included in the analysis. Mean age was 74.1 ± 5.8 years in 2002, 76.0 ± 8.3 years in 2014, 98% male, and 87.5% White. In 2002, the median (interquartile range) frailty score was 0.16 (0.10-0.23). This increased and stabilized to 0.19 (0.10-0.32) for 2006-14. The presence of frailty was associated with an increased risk of CV mortality at every stage of frailty. Frailty was associated with an increased risk of myocardial infarction and stroke, but not revascularization.

CONCLUSION

In this population, both the presence and severity of frailty are tightly correlated with CV death, independent of underlying CV disease. This study is the largest and most contemporary evaluation of the relationship between frailty and CV mortality to date. Further work is needed to understand how this risk can be diminished.

KEY QUESTION

Can an electronic frailty index identify adults aged 65 and older who are at risk of CV mortality and major CV events?

KEY FINDING

Among 3 068 439 US Veterans aged 65 and older, frailty was associated with an increased risk of CV mortality at every level of frailty. Frailty was also associated with an increased risk of myocardial infarction and stroke, but not revascularization.

TAKE HOME MESSAGE

Both the presence and severity of frailty are associated with CV mortality and major CV events, independent of underlying CV disease.

Incidence of cardiovascular disease and mortality in underweight individuals

BACKGROUND

Few studies have evaluated the association between being underweight and having cardiovascular disease in the general population. We investigated the incidence of stroke, myocardial infarction (MI), and all-cause mortality according to detailed underweight categories in a large population cohort.

METHODS

We included 4 164 364 individuals who underwent a health examination that was conducted as part of the Korean National Health Insurance Service between January 2009 and December 2012 and followed them up to determine the incidence of stroke, MI, and all-cause mortality until 31 December 2016. Based on the body mass index, the study population was categorized into normal (18.50-22.99), mild (17.00-18.49), moderate (16.00-16.99), and severe underweight (<16.00) groups. Cox proportional hazards analyses were performed to calculate the hazard ratio for stroke, MI, and mortality according to the severity of underweight in reference to the normal weight. We adjusted for age, sex, lifestyle, economic status, co-morbidity, blood pressure, glucose, lipid level, and waist circumference.

RESULTS

The mean age of the 4 164 364 eligible subjects in this study cohort was 44.4 ± 14.3 years, and 46.1% of the participants were male; 46 728 strokes, 30 074 MIs, and 121 080 deaths occurred during 27 449 902 person-years. The incidence of stroke, MI, and all-cause mortality increased proportionally with the severity of underweight in the multivariate model. This proportional association became more evident when the waist circumference was additionally adjusted. The respective hazard ratios (95% confidence intervals) for mild, moderate, and severe underweight were 1.10 (1.06-1.15), 1.11 (1.02-1.20), and 1.38 (1.24-1.53) for stroke; 1.19 (1.14-1.25), 1.40 (1.27-1.53), and 1.86 (1.64-2.11) for MI; and 1.63 (1.60-1.67), 2.10 (2.02-2.17), and 2.98 (2.85-3.11) for all-cause mortality. In stratified analyses based on waist circumference, the severity of underweight was consistently associated with a higher risk of stroke, MI, and death.

CONCLUSIONS

The severity of underweight was associated with a higher risk of stroke, MI, and all-cause mortality.

Frailty Scores and Their Utility in Older Patients with Cardiovascular Disease

The world’s population is ageing, resulting in more people with frailty receiving treatment for cardiovascular disease (CVD). The emergence of novel interventions, such as transcatheter aortic valve implantation, has also increased the proportion of older patients being treated in later stages of life. This increasing population burden makes the assessment of frailty of utmost importance, especially in patients with CVD. Despite a growing body of evidence on the association between frailty and CVD, there is no consensus on the optimal frailty assessment tool for use in clinical settings. Previous studies have shown limited concordance between validated frailty instruments. This review evaluates the evidence on the utility of frailty assessment tools in patients with CVD, and the effect of frailty on different outcomes measured.

Benchside to the bedside of frailty and cardiovascular aging: Main shared cellular and molecular mechanisms

Due to the impact that frailty and cardiac aging have on society and health systems, the mechanisms surrounding these conditions must be known. If the frailty and cardiovascular complications are due to numerous controllable factors or not, different strategies must be considered to improve the elderly patient's prognosis and improve their quality of life. This review aimed to investigate the main shared mechanisms of cardiac aging and frailty. MEDLINE-PubMed, Cohrane and EMBASE databases were searched to perform this review. The mesh-terms used for this search was frailty, cardiovascular disease, cardiovascular aging, or heart failure (HF). Frailty frequently coexists with heart conditions since they share predisposing pathophysiological alterations, the aging process, and elevated comorbidity burden, contributing to fast functional decline and sarcopenia. Mitochondrial dysfunctions and decreased protein synthesis lead to protein degradation, denervation, atrophy, impairment in the fatty acid oxidation, resulting in cardiomyopathy. The homeostasis of muscle metabolism deteriorates with aging, leading to a reduction in muscle quality and quantity. The installation of a low-grade and chronic inflammatory process adds to an impairment in glucose, protein and lipid metabolism, endothelial dysfunction, cardiovascular conditions, sarcopenia, and HF. The exacerbated rise in inflammatory biomarkers and impaired insulin resistance leads to worsening of the patient's general condition. The good news is that frailty is a dynamic syndrome, fluctuating between different states of seriousness but still has potential for reversibility based on physical activity, cognitive training, nutrition intervention, and a plethora of other approaches that can be performed by a multi-disciplinary team.

Association between Frailty and Albuminuria among Older Chinese Inpatients

OBJECTIVES

Older adults with frailty are vulnerable to cardiovascular event and subsequent mortality. Frailty and albuminuria share atherosclerotic risk factors. The present study investigated the association of frailty and albuminuria among elderly Chinese inpatients.

DESIGN

Cross-sectional study.

SETTINGS AND PARTICIPANTS

A total of 202 patients aged over 60 years from the Center of Gerontology and Geriatric, West China Hospital.

MEASUREMENTS

Frailty was defined using the five-item FRAIL scale. This included measurements of fatigue, resistance, ambulation, illness, and loss of weight. We further determined the random urine albumin/creatinine ratio (UACR) of all patients. Random UACR ≥30 mg/g was defined as albuminuria, and < 30mg/g as normoalbuminuria. The relationship between albuminuria and frailty was assessed through multiple regression analysis.

RESULTS

The 202 participants (156 men, 77.2%) had an average age of 78.99±7.60 years, which ranged from 60 to 95. Compared to those without albuminuria, elderly patients with albuminuria were of an older age, had a higher prevalence of diabetes and poorer renal function. The prevalence of frailty, pre-frailty and ambulation (one of the FRAIL components) were higher in the albuminuria group than the normoalbuminuria group (23.9% vs. 12.2%, 47.9% vs.37.4%, 33.8% vs. 16.0%, respectively, P<0.05). Following the adjustment for age, eGFR, hypertension, diabetes and using ACEI/ARB, being frail or pre-frail led to an enhanced risk of albuminuria (OR frail 2.60, 95% CI frail 1.01-6.72; OR pre-frail 2.14, 95% CI pre-frail 1.03-4.44).

CONCLUSIONS

Frailty is independently associated with albuminuria when adjusted for classic cardiovascular risk factors.

Multimorbidity, physical frailty, and self-rated health in older patients with atrial fibrillation

BACKGROUND

Holistic care models emphasize management of comorbid conditions to improve patient-reported outcomes in treatment of atrial fibrillation (AF). We investigated relations between multimorbidity, physical frailty, and self-rated health (SRH) among older adults with AF.

METHODS

Patients (n = 1235) with AF aged 65 years and older were recruited from five medical centers in Massachusetts and Georgia between 2015 and 2018. Ten previously diagnosed cardiometabolic and 8 non-cardiometabolic conditions were assessed from medical records. Physical Frailty was assessed with the Cardiovascular Health Study frailty scale. SRH was categorized as either "excellent/very good", "good", and "fair/poor". Separate multivariable ordinal logistic models were used to examine the associations between multimorbidity and SRH, physical frailty and SRH, and multimorbidity and physical frailty.

RESULTS

Overall, 16% of participants rated their health as fair/poor and 14% were frail. Hypertension (90%), dyslipidemia (80%), and heart failure (37%) were the most prevalent cardiometabolic conditions. Arthritis (51%), anemia (31%), and cancer (30%), the most common non-cardiometabolic diseases. After multivariable adjustment, patients with higher multimorbidity were more likely to report poorer health status (Odds Ratio (OR): 2.15 [95% CI: 1.53-3.03], ≥ 8 vs 1-4; OR: 1.37 [95% CI: 1.02-1.83], 5-7 vs 1-4), as did those with more prevalent cardiometabolic and non-cardiometabolic conditions. Patients who were pre-frail (OR: 1.73 [95% CI: 1.30-2.30]) or frail (OR: 6.81 [95% CI: 4.34-10.68]) reported poorer health status. Higher multimorbidity was associated with worse frailty status.

CONCLUSIONS

Multimorbidity and physical frailty were common and related to SRH. Our findings suggest that holistic management approaches may influence SRH among older patients with AF.

Associations of Sleep Quality and Frailty among the Older Adults with Chronic Disease in China: The Mediation Effect of Psychological Distress

Frailty affects the elderly and leads to adverse health outcomes. Preliminary evaluations have suggested that sleep quality and psychological distress are predictors of frailty among older adults. However, the mechanisms by which sleep quality affect frailty had not been fully addressed in the previous research. This study aimed to explore the mediation effect of psychological distress on the association between sleep quality and frailty among the elderly with chronic diseases in rural China. A total of 2346 old adults were included in the analysis. Frailty status was measured by Fried Phenotype criteria. Sleep quality was assessed by Pittsburgh Sleep Quality Index (PSQI), and psychological distress was examined by Kessler Psychological Distress Scale (K10). Ordinal logistic regressions were performed to assess the relationships between sleep quality and frailty. Mediation test was also conducted by bootstrap method. The prevalence rate of frailty among the elderly with chronic diseases was 21% in rural China. Compared with the elder of robust status, respondents identified as having frailty have lower SES, less vigorous physical activity, and worse self-reported health status. Poor sleep quality was a significant predictor of frailty with mediators (OR = 1.44, 95% CI = 1.19-1.76). Mediation analysis suggested that psychological distress mediated 41.81% of total effect between sleep quality and frailty. This study indicated that poor sleep quality was significantly related to frailty, and psychological was a mediator of this association. However, we could not investigate causal relationships between variables since this was one cross-sectional study. These findings suggested that an early detection of sleep problems and also psychological disorders should be taken to prevent frailty among the rural older adults in China.

Weight Change and Mortality from Cardiovascular Diseases: The Japan Collaborative Cohort Study

Aim: The aim of this study was to assess the association between weight change and mortality due to cardiovascular diseases (CVDs) in a Japanese population.

Methods: We used the data of a population-based prospective cohort study that was conducted from 1988 to 1990 in 45 areas throughout Japan. Among a total of 69,681 men and women aged 40–79 with no history of CVD or cancer at baseline, the association between weight change from 20 years of age to baseline and CVD-related mortality was evaluated.

Results: During a median follow-up period of 19.1 years, we observed 4,274 deaths from total CVD. After adjusting for age, sex, and other potential confounding factors, compared with participants with a weight change of < 2.5 kg (stable weight), participants with a greater weight change (either loss or gain) had an increased risk of mortality from total CVD (U-shaped association). The hazard ratios for the total CVD risk in participants with a weight loss and a weight gain of ≥ 12.5 kg were 1.50 (95% confidence interval [CI], 1.30–1.72) and 1.21 (95% CI, 1.07–1.36), respectively. The associations between weight change and risk of mortality from ischemic heart disease or stroke showed similar trends. The risk of intracerebral hemorrhage was associated with weight loss only. Weight change was not associated with mortality from subarachnoid hemorrhage.

Conclusions: Weight loss or gain could be a risk factor for mortality from total or ischemic CVD, while weight loss could be a risk factor for intracerebral hemorrhage.

Oxidative Stress, Frailty and Cardiovascular Diseases: Current Evidence

The aim of this chapter is to review the results of recent studies analyzing the role of oxidative stress and systemic inflammation as potential contributors to frailty and CVD, and to explain a possible pathogenic relationship between the latter two conditions. Available evidence suggests that frail patients have elevated levels of oxidative stress biomarkers and proinflammatory cytokines, as well as with reduced concentrations of endogenous antioxidants. This implies that oxidative stress and systemic inflammation might play a role in the pathogenesis of frailty, but an underlying mechanism of this relationship is still mostly hypothetical. Oxidative stress and systemic inflammation are also involved in the pathogenesis of CVD. Cardiovascular conditions are established risk factor for frailty and in turn, presence of frailty constitutes an unfavorable prognostic factor in cardiac patients. Finally, some cardiovascular risk factors, such as lack of physical activity, smoking, obesity and inappropriate diet, are also involved in the etiology of oxidative stress, chronic inflammation and frailty. This complex interplay between intrinsic and extrinsic elements should be considered during holistic management of older persons with frailty and/or cardiovascular conditions.

The relationship between antecedent creatinine decreases and outcomes in patients undergoing hemodialysis

INTRODUCTION

Previous studies have demonstrated an association between low serum creatinine levels and adverse outcomes in patients undergoing maintenance hemodialysis. However, little is known regarding whether long-term changes in serum creatinine predict outcomes independently and incrementally over a single point evaluation.

METHODS

Serum creatinine data at index (June 2013) and for the 18 months prior to the index blood sampling (between January 2012 and June 2013) were evaluated in 346 hemodialysis patients. Patients were followed from the index blood sampling for primary (all-cause mortality) and secondary (cardiovascular death) endpoints.

FINDINGS

During a median follow-up of 5.7 years, there were 82 all-cause and 25 cardiovascular deaths. Compared to patients who survived, those who died displayed a greater time-dependent reduction in creatinine levels during the 18 months prior to the index assessment, coupled with a greater decrease in predialysis body weight (interaction p = 0.007). Patients who displayed creatinine decline over the prior 18 months (∆ creatinine<0 mg/dL) had higher all-cause mortality than those who maintained creatinine levels (∆ creatinine≥0 mg/dL). After adjustment for clinical factors and baseline creatinine index, antecedent creatinine decrease was independently associated with an increased risk of all-cause mortality, with an incremental prognostic value over baseline creatinine index alone. A reduction in creatinine levels was also associated with cardiovascular death independent of the baseline creatinine index.

DISCUSSION

A long-term antecedent decrease in serum creatinine levels is independently associated with clinical outcomes in hemodialysis patients, with an incremental prognostic value over baseline creatinine index alone. Our data suggest that serial creatinine measurements are a useful prognosticator in practice.

Cardiovascular Disease and Frailty: What Are the Mechanistic Links?

BACKGROUND

In aging populations, cardiovascular disease (CVD) and frailty are common and often coexist. It is possible that common risk factors and pathophysiological pathways increase the risk of both CVD and frailty.

CONTENT

Frailty is a complex clinical syndrome with multiple causes and contributing factors. It is characterized by multisystem impairment that decreases physiological reserve and increases vulnerability to stress. Diverse methods have been used to evaluate frailty. Most include 1 or several measures related to reduced exercise, physical function, cognition, activities of daily living, comorbidities, deficits and/or markers of physiological dysfunction. CVD and frailty may be linked by several mechanisms. CVD can accelerate frailty, and frailty increases the risk of adverse outcomes in patients with CVD. Common pathophysiological pathways are also important. Low physical activity, poor nutrition, diabetes, hypertension, and smoking may increase the risk of both CVD and frailty. Further research is needed to evaluate whether biomarkers of dysfunction across multiple body systems, which are known to be associated with aging, and with CV and non-CV morbidity and mortality, are also associated with frailty.

SUMMARY

Multiple pathophysiological pathways are associated with both CVD and frailty, which interact to further increase the risk of adverse outcomes.