The frailty syndrome is associated with adverse health outcomes in very old patients with stable heart failure: A prospective study in six Spanish hospitals

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Abstract

Background

Most studies on the association between the frailty syndrome and adverse health outcomes in patients with heart failure (HF) have used non-standard definitions of frailty. This study examined the association of frailty, diagnosed by well-accepted criteria, with mortality, readmission and functional decline in very old ambulatory patients with HF.

Methods

Prospective study with 497 patients in six Spanish hospitals and followed up during one year. Mean (SD) age was 85.2 (7.3) years, and 79.3% had LVEF > 45%. Frailty was diagnosed as having ≥ 3 of the 5 Fried criteria. Readmission was defined as a new episode of hospitalisation lasting > 24 h, and functional decline as an incident limitation in any activity of daily living at the 1-year visit. Statistical analyses were performed with Cox and logistic regression, as appropriate, and adjusted for the main prognostic factors at baseline.

Results

At baseline, 57.5% of patients were frail. The adjusted hazard ratio (95% confidence interval) for mortality among frail versus non-frail patients was 1.93 (1.20–3.27). Mortality was higher among patients with low physical activity [1.64 (1.10–2.45)] or exhaustion [1.83 (1.21–2.77)]. Frailty was linked to increased risk of readmission [1.66 (1.17–2.36)] and functional decline [odds ratio 1.67 (1.01–2.79)]. Slow gait speed was related to functional decline [odds ratio 3.59 (1.75–7.34)]. A higher number of frailty criteria was associated with a higher risk of the three study outcomes (P trend < 0.01 in each outcome).

Conclusions

Frailty was associated with increased risk of 1-year mortality, hospital readmission and functional decline among older ambulatory patients with HF.

Introduction

Frailty is an age-associated medical syndrome characterised by increased vulnerability to even minor stressors, which manifests as higher risk of adverse health outcomes including disability, hospitalisation and death [1], [2]. And heart failure (HF) is the most common cause of hospital admission in individuals aged 65 years or older and shows a high risk of mortality, disability and hospital readmission [3], [4], [5], [6].

Of note is that frailty and HF are frequently associated [7]; indeed, it has been suggested that these two syndromes share common pathogenic mechanisms [8] and that some treatment modalities, such us physical exercise, benefit both of them [9], [10]. Very old patients with HF show a high prevalence of frailty and disability [11], [12], [13], and their mortality depends on the degree of functional and cognitive impairment [14], [15], [16] ; moreover frailty has also been linked to greater functional decline and higher risk of hospital readmission and death in these patients [9], [11], [17], [18], [19].

However, knowledge of the prognostic relevance of frailty in HF is rather limited. In fact, some studies have included relatively young patients with a mean age of 66–68 years, who mostly had reduced left-ventricle ejection fraction (LVEF) [12], [20], [21]. In other investigations, patients were recruited during a hospitalisation episode [11], [14], [19], [22], [23], which may contribute to deconditioning and increase the frequency of frailty. Moreover, several studies only selected patients in good functional condition [11], or in specific settings like the community [24] and cardiology clinics [20], [21]. And most importantly, a number of investigations used non-standard definitions of frailty, such as disability, functional decline or cognitive impairment [14], [20], [21], [24], and other studies simply focused on indicators or individual components of the frailty phenotype [6], [25], [26], [27].

Thus, the influence of frailty, based on widely-accepted diagnostic criteria, on the prognosis of very old patients with stable HF is still uncertain. Accordingly, we examined the association of the frailty syndrome with mortality, readmission and functional decline in very old ambulatory patients after a hospital discharge for HF.

Section snippets

Study design and participants

This study was conducted with ambulatory patients discharged from six Spanish hospitals with a main diagnosis of HF from December 1, 2010 to November 30, 2012. Patients were previously admitted to the Geriatric Medicine or Cardiology departments, and referred to the Geriatric Medicine specialised outpatient clinic when they met the following inclusion criteria: a) age  75 years on recruitment; b) HF diagnosis according to Framingham [28] and European Society of Cardiology [29] criteria; c) having

Baseline characteristics of study participants

Table 1, Table 2 show the baseline characteristics of participants according to frailty status. In comparison with non-frail patients, those with frailty were older, were more frequently women, and were more often living with family members other than the spouse. They were also more likely to suffer from dementia and to be treated with aldosterone antagonist drugs, and showed worse NYHA functional class and higher NTproBNP (Table 1). Lastly, frail patients more frequently showed limitations in

Discussion

In this multicentre study in Spain, the frailty syndrome was associated with an increased risk of 1-year mortality, hospital readmission and functional decline among very old ambulatory patients with HF. When frailty criteria were considered separately, low physical activity and exhaustion were linked to increased mortality, and slow gait speed to functional decline. Moreover, a higher number of frailty criteria at baseline was associated with a progressively higher risk of the three study

Conclusion

Frailty is a frequent finding in very old patients with stable HF, which substantially increases the risk of adverse outcomes including mortality, hospital readmission and functional decline. Because of this, treatment of HF must be optimised in frail patients. Moreover, future research should establish if well-accepted treatments of frailty (physical exercise, vitamin D, caloric and protein support, reduction of polypharmacy) [46] improve prognosis in these patients.

Funding

This work has been partially funded by the Instituto de Salud Carlos III, C/ Sinesio Delgado, 4, 28029 Madrid, Spain (grants PI08/1280, PI09/91064, and PI14/01044).

Conflict of interest

The authors report no relationships that could be construed as a conflict of interest.

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    All authors take responsibility for all aspects of the reliability and freedom from bias of the data presented and their discussed interpretation.

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