Frailty: A New Vital Sign in Heart Failure Comes of Age

Frailty is a state of reduced physiological capacity across multiple body systems that increases vulnerability and poor health outcomes in older adults. Although frailty is common, particularly amongst people with cardiovascular disease, it often goes unrecognized. In a recent companion editorial published in the European Heart Journal (referring to the article ‘Frailty and outcomes in heart failure patients from high-, middle-, and low-income countries’, by D.P. Leong, et al.), Dr. Finlay McAlister outlines that measures of frailty are not included in current heart failure prognostic models, and why they should be. 

Many clinicians presume frailty is just a marker of biological age and/or comorbidities, and is therefore already captured by standard prognostic scores based on those variables. The study published by Leong and colleagues confirmed that the strong correlation between frailty/pre-frailty and worse outcomes in patients with heart failure is consistent across countries of varying income levels, is present within the vast majority of clinical subgroups, and is independent of many conventional heart failure prognostic scores. Their findings further demonstrate that frailty assessments provide incremental prognostic value for predicting the risk of mortality or hospitalization in patients with heart failure, beyond standard clinical evaluations.

Identifying frailty is also thought to be challenging. Published research shows that the two most commonly used frailty assessment models are relatively accurate, and, as Leong et al. illustrate, both are independently predictive of death or hospitalization, and, accordingly, either or both could play a role in prognostication and risk stratification. Dr. McAlister acknowledges that further research is required to establish which method best identifies reversible frailty in patients with heart failure, or whether developing a new method is required to achieve this end. In addition to better understanding prognostication through identification, Leong et al. assert that addressing frailty may be a new strategy that could directly improve outcomes for patients with heart failure. Additionally, Dr. McAlister highlights the importance of assessing frailty in heart failure to better individualize care and improve treatment strategies for a patient population who are at a higher risk of death and hospitalization. 

In order to ensure heart failure patients with frailty receive the best care, Dr. McAlister emphasizes the importance of expanding eligibility criteria to include a wider range of frail patients in future clinical trials, and developing a more robust evidence base for frailty outcomes as well as cardiac outcomes, thus further ensuring future guidelines better address the risk factors and treatment gaps faced by this patient population.