The frailty syndrome and mortality among very old patients with symptomatic severe aortic stenosis under different treatments☆
Introduction
Frailty is a geriatric syndrome characterized by increased vulnerability to even minor stressors, which results from a decline in multiple physiologic systems [1], [2], [3], [4]. Given that the frailty syndrome predicts adverse clinical outcomes (hospitalization, institutionalization or death), frailty assessment has been recommended to guide treatment decisions in patients with SAS [5], [6], [7]. Specifically, several studies in patients undergoing cardiac surgery and transcatheter aortic valve replacement (TAVR) have shown that frailty is a risk factor for mortality, functional decline, and institutionalization [8], [9]. The risk of perioperative mortality and institutionalization at discharge [8], [10], [11], [12], as well as one-year mortality [13], is also increased in frail cardiac surgery patients. Moreover, frail SAS patients treated with TAVR are at higher risk of perioperative and one-year mortality [14], [15], functional decline at 6 months [16], and one-year major cardiovascular and cerebral adverse events [17]. However, these studies have included selected groups of patients and have used different measures of frailty, which have sometimes combined frailty and disability. Therefore, no previous studies have specifically analyzed the role of frailty as a prognostic factor in non-selected elderly patients with SAS undergoing different types of treatments.
Although the diagnosis of frailty is usually based on the coexistence of a number of criteria [1] or the accumulations of deficits [3], it has been suggested that gait speed could be a simple measure of frailty [18], [19]. This is based on the fact that slowness is a good predictor of morbidity and mortality in community-dwelling older adults [20], [21], [22], [23], in patients with coronary heart disease [24] and in those undergoing cardiac surgery [11]; nevertheless, Green et al. did not find an association of gait speed with one-year mortality in patients with SAS under TAVR treatment [15]. Low grip strength has also been linked to worsen survival in older adults living in the community [25], but the association between strength and mortality has not yet been studied in patients with SAS. Thus, the role of gait speed, grip strength, and the other components of the frailty phenotype in the prognosis of SAS patients under different treatment modalities is still uncertain.
This study examined the association between the frailty syndrome and mortality in very old patients with symptomatic SAS; it also assessed whether the association varied with the type of SAS treatment and identified the individual frailty criteria which were associated with mortality risk.
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Study design and participants
This study included consecutive ambulatory patients diagnosed with SAS who were recruited between February 1, 2010 and January 30, 2015 from the department of echocardiography in one hospital. We also checked with the cardiac surgery and interventional cardiology departments to ensure that all patients meeting inclusion criteria were recruited. To be included, patients had to fulfill three criteria: a) Age 75 years or older; b) Echocardiography-based criteria for SAS, such as valvular area ≤ 1 cm2
Results
At baseline, 49.3% of patients were frail. In total, 45.7% of patients were under medical SAS treatment, while 18% underwent TAVR and 36.3% received SAVR. The most frequent reasons for not performing SAVR were symptoms that did not limit ADLs (47.8%), patient's own decision (37.2%), severe comorbidity (37.2%), severe disability (23.9%), severe frailty (20.3%) and extremely old age (6.6%).
The baseline characteristics of patients according to frailty status are shown in Table 2. Compared to
Discussion
This is the first prospective study which has examined the relationship between the frailty syndrome and mortality in very old patients with SAS under different treatments. The main findings are that frailty is associated with increased mortality independently of many sociodemographic and clinical variables, and that this association holds regardless of the specific SAS treatment. Moreover, slow gait speed and low physical activity are linked to increased mortality independently of the other
Limitations of the study
Our study had some limitations. First, since frailty should be assessed in clinically stable patients, individuals who were diagnosed with SAS and received SAVR or TAVR during a hospital admission due to an acute disease were not included in the study. However, this occurred in only a very small number of cases, so it is not likely to affect the generalizability of the study findings. Second, given that the frailty phenotype is based on dichotomous criteria, the severity of frailty could not be
Conclusions
Frailty, assessed with the Fried criteria, is associated with increased mortality during a mean 98-week follow-up, and this association does not vary with the type of SAS treatment (medical, transcatheter aortic valve replacement, or surgical aortic valve replacement). Mortality is also higher among patients with slow gait speed or low physical activity.
Given that frailty is associated with mortality in SAS patients, future studies evaluating the benefits of different treatments in SAS patients
Funding
This work has been partially funded by the Instituto de Salud Carlos III, C/Sinesio Delgado, 4, 28029 - Madrid (grant PI11/00640) and the Spanish Society of Geriatrics and Gerontology, Príncipe de Vergara, 57-59 28006 Madrid (research prize 2011).
Discolosures
None to declare.
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