Frailty as measured by the Essential Frailty Toolset (EFT) was the strongest predictor of death and disability in older adults after transcatheter aortic valve replacement (TAVR) or surgical aortic valve replacement (SAVR), according to a study published July 7 in the Journal of the American College of Cardiology.

FRAILTY-AVR, the largest prospective study to date to examine frailty in this population, found there was incremental predictive value above existing risk models when frailty was measured objectively with a validated scale.

The EFT, consisting of just four items (the time required to stand 5 times from a seated position without using arms, cognition, hemoglobin and serum albumin), was compared against six other frailty scales. In addition, they assessed the patients' physical activity, comorbidities, procedural details, pre- and post-procedural laboratory results, and echocardiography, cardiac catheterization, and computed tomography data. The predicted risk of mortality (PROM) was calculated using the Society of Thoracic Surgeons (STS) risk model. The primary outcome was death from any cause at 12 months.

A total of 646 patients underwent TAVR and 374 underwent SAVR. Their median age was 82 years and overall median STS-PROM was 4.3 percent. There were 145 (14 percent) deaths during the first year. The prevalence of frailty ranged from 26 percent to 68 percent, depending on the scale used. Frailty was highest among nonsurvivors and was two-fold higher in TAVR than SAVR patients.

On multivariate analysis, the EFT had the strongest association with one year mortality (odds ratio [OR], 3.72). Compared with the other frailty scales, EFT provided the greatest incremental predictive value for mortality in a model including the STS-PROM and procedure type. The EFT also was the best predictor of death or worsening disability (OR, 2.13), which occurred in 35 percent of patients at one year, and was associated with an adjusted OR of 3.29 for 30-day mortality.

The authors state that although the likelihood of procedural success and short-term survival was very high in the study, the incidence of subsequent functional decline and poor patient-centered outcomes at one year was 35 percent overall – and greater than 50 percent in patients who were frail.

In recommending the evaluation of frailty in this population, they write, "The advantages of the EFT, beyond its predictive value, are that it is quick to perform, it does not require specialized equipment, and, importantly, its components have high interobserver reliability and are actionable."

Keywords: Aged, 80 and over, Incidence, Odds Ratio, Aortic Valve, Prevalence, Transcatheter Aortic Valve Replacement, Prospective Studies, Comorbidity, Serum Albumin, Multivariate Analysis, Reproducibility of Results, Cardiac Catheterization, Heart Valve Prosthesis, Risk, Probability, Hemoglobins, Echocardiography, Exercise, Cognition, Surgeons, Tomography

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