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Identification of Frailty in Chronic Heart Failure
Study Questions:
What is the prevalence of frailty, classification performance, and agreement among three frailty assessment tools and three screening tools in patients with chronic heart failure (CHF)?
Methods:
The study cohort was comprised of consecutive ambulatory patients with CHF (with a diagnosis of ≥1 year) attending a community HF clinic. The study authors utilized the clinical frailty scale (CFS; scored according to their functional capacity, level of dependence, and comorbidities); the Derby frailty index; and the acute frailty network frailty criteria. And they used the following frailty assessment tools: the Fried criteria (weak grip strength, unintentional weight loss, exhaustion, slow walking speed, and low physical activity); the Edmonton frailty score (based on the concept of multidimensional frailty); and the Deficit Index (which quantifies the cumulative burden of deficits). Comorbidities were measured using the Charlson comorbidity index/score. Because there is no gold standard in evaluating frailty in patients with CHF, for each of the frailty tools, the authors used the results of the other five tools to produce a single combined frailty index that they assumed to be the gold standard frailty tool.
Results:
The final study cohort was comprised of 467 consecutive patients with CHF (67% male; median age, 76 years; interquartile range [IQR], 69-82 years; median N-terminal pro–B-type natriuretic peptide [NT-proBNP], 1,156 ng/L [IQR, 469-2,463 ng/L]) and 87 control patients (79% male; median age, 73 years [IQR, 69-77 years]). The majority of patients and control patients were male and elderly; 17% of those with CHF were ≥85 years (vs. 2% of control patients). Most of the patients with CHF had HF with reserved ejection fraction (HFrEF) (62%) with a median NT-proBNP >1,100 ng/L; approximately one-fifth of these patients had severe symptoms (New York Heart Association [NYHA] class III/IV). The prevalence of frailty using the different tools was higher in CHF patients than in control patients (30-52% vs. 2-15%, respectively). The prevalence of frailty was higher in patients with HF with preserved EF (HFpEF) than HFrEF patients. The prevalence of frailty was higher in patients with atrial fibrillation than in those in sinus rhythm. The prevalence of frailty increased with more comorbidities, decreasing body mass index and increasing NYHA, age, and NT-proBNP. Of the screening tools, CFS had the strongest correlation and agreement with the assessment tools (correlation coefficient, 0.86-0.89; Kappa coefficient, 0.65-0.72, depending on the frailty assessment tools; all p < 0.001). CFS had the highest sensitivity (87%) and specificity (89%) among screening tools and the lowest misclassification rate (12%) among all six frailty tools in identifying frailty according to the standard combined frailty index.
Conclusions:
The study authors concluded that frailty is common in CHF patients and is associated with increasing age, comorbidities, and severity of HF. CFS is a simple screening tool that identifies a similar group using more lengthy assessment tools.
Perspective:
As the burden of comorbidities increases with age, the assessment of frailty will be a part of the routine assessment of all HF patients in the not too distant future. More data need to be collected to confirm that assessment of frailty adds incremental value to HF prognosis determined by NYHA class.
Keywords: Atrial Fibrillation, Body Mass Index, Comorbidity, Exercise, Frail Elderly, Geriatrics, Heart Failure, Natriuretic Peptide, Brain, Peptide Fragments, Secondary Prevention, Stroke Volume, Weight Loss
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