Frailty is common among older adults living with cardiovascular disease (CVD).(1,2) Despite methodological and conceptual debates regarding the optimal method to assess frailty, there is general agreement in defining frailty as a state of increased vulnerability to stressors, with limited reserves to stabilize declines across multiple physiologic systems.(3) Frail adults with CVD typically suffer with worse disease outcomes, as well as increased susceptibility to harmful effects from standard therapies. Prior studies revealed that older adults who exhibited frailty were less likely to receive the same extent of therapy as compared to adults without frailty.(2,4) For example, the use of guideline-directed medical therapy with ACEi and beta-blockers was lower when frailty was encountered, and these patients were less likely to be admitted to coronary care units and to undergo cardiac catheterization or coronary artery bypass surgery.(2,5,6) Furthermore, adults ≥80 years usually have higher prevalence diabetes mellitus, HF, atrial fibrillation, renal failure, anemia, chronic kidney disease, and dementia.(2,7,8) As such, treatment with invasive procedures that requires prolonged dual anti-platelet therapy with or without the need for anti-thrombotic therapy for cerebrovascular vascular accident prevention, may not produce the same results in comparison to younger counterparts with a single disease process. The risk of contrast induced nephropathy after coronary angiography is higher in older adults, which often reinforces rationale for conservative approaches. Generally, pharmacotherapy is challenging in older adults as reduced renal function results in different bioavailability and drug elimination profiles. Drug-drug and drug-disease interactions are common specially in setting of polypharmacy.(9) Intolerance to beta-blockers because of underlying fatigue may exert a significant challenge to achieve a reduced work load of the heart.


The presence of frailty in very old adults also contributes to longer hospital length of stay, increased rehospitalization, increased bleeding, and greater cardiovascular mortality.(2,10-12) Because of higher risk of bleeding, the use of multiple antithrombotic and antiplatelet agents is particularly challenging.(13) In older adults with acute coronary syndrome and concomitant atrial fibrillation who require oral antithrombotic therapy, prolonged dual antiplatelet therapy after PCI with oral antithrombotic therapy increases the long-term risk of bleeding events in frailty patients. In older patients with myocardial infarction, early revascularization results in improved clinical outcomes and better symptom control.


Key points:

  • Frailty is an important clinical condition that can affect clinical decision making for older patients with acute or chronic cardiovascular disease.
  • Frailty can progressively worsen outcomes after cardiovascular disease, and better integration of frailty assessment tools in the management of all forms of cardiovascular illness is critical. 
  • Research on whether the accelerated decline in health among frail older patients with cardiovascular disease may be mitigated by early mobility, incentive spirometry, physical therapy, and nutritional enrichment are need for acute cardiac care in older patients.
  • As the U.S. population grows older, futility assessment, to include frailty and multisystem dysregulation, for older patients undergoing invasive cardiovascular therapies is an area that needs urgent attention from the clinical and research communities.


Cardiology References


1.         Veronese N, Cereda E, Stubbs B et al. Risk of cardiovascular disease morbidity and mortality in frail and pre-frail older adults: Results from a meta-analysis and exploratory meta-regression analysis. Ageing Res Rev 2017;35:63-73.

2.         Damluji AA, Ramireddy A, Forman DE. Management and Care of Older Cardiac Patients. In: Vasan RS, Sawyer DB, editors. Encyclopedia of Cardiovascular Research and Medicine. Oxford: Elsevier, 2018:245-265.

3.         Clegg A, Young J, Iliffe S, Rikkert MO, Rockwood K. Frailty in elderly people. Lancet 2013;381:752-62.

4.         Lupon J, Gonzalez B, Santaeugenia S et al. Prognostic implication of frailty and depressive symptoms in an outpatient population with heart failure. Rev Esp Cardiol 2008;61:835-42.

5.         Afilalo J, Alexander KP, Mack MJ et al. Frailty assessment in the cardiovascular care of older adults. J Am Coll Cardiol 2014;63:747-62.

6.         Graham MM, Galbraith PD, O’Neill D, Rolfson DB, Dando C, Norris CM. Frailty and outcome in elderly patients with acute coronary syndrome. Can J Cardiol 2013;29:1610-5.

7.         Alexander KP, Newby LK, Cannon CP et al. Acute coronary care in the elderly, part I: Non-ST-segment-elevation acute coronary syndromes: a scientific statement for healthcare professionals from the American Heart Association Council on Clinical Cardiology: in collaboration with the Society of Geriatric Cardiology. Circulation 2007;115:2549-69.

8.         Mogensen UM, Ersboll M, Andersen M et al. Clinical characteristics and major comorbidities in heart failure patients more than 85 years of age compared with younger age groups. Eur J Heart Fail 2011;13:1216-23.

9.         Fihn SD, Gardin JM, Abrams J et al. 2012 ACCF/AHA/ACP/AATS/PCNA/SCAI/STS Guideline for the diagnosis and management of patients with stable ischemic heart disease: a report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines, and the American College of Physicians, American Association for Thoracic Surgery, Preventive Cardiovascular Nurses Association, Society for Cardiovascular Angiography and Interventions, and Society of Thoracic Surgeons. J Am Coll Cardiol 2012;60:e44-e164.

10.      Alonso Salinas GL, Sanmartin Fernandez M, Pascual Izco M et al. Frailty is a short-term prognostic marker in acute coronary syndrome of elderly patients. Eur Heart J Acute Cardiovasc Care 2016;5:434-40.

11.      Ekerstad N, Swahn E, Janzon M et al. Frailty is independently associated with short-term outcomes for elderly patients with non-ST-segment elevation myocardial infarction. Circulation 2011;124:2397-404.

12.      Alonso Salinas GL, Sanmartin Fernandez M, Pascual Izco M et al. Frailty predicts major bleeding within 30days in elderly patients with Acute Coronary Syndrome. Int J Cardiol 2016;222:590-3.

13.      Forman DE, Alexander K, Brindis RG et al. Improved Cardiovascular Disease Outcomes in Older Adults. F1000Res 2016;5.