Frailty is common among older adults living with cardiovascular disease (CVD). Across the spectrum of heart disease, prevalence estimates of physical frailty have been reported at 52% among those with systolic and diastolic heart failure (Sze et al., 2019), 42% in those with acute coronary syndrome (Núñez et al., 2020), and 37% in those with valvular heart disease (Afilalo et al., 2017).
A leading hypothesis suggests that the high levels of inflammation associated with aging - “inflammageing” - is a strong risk factor for both cardiovascular disease and frailty (Ferrucci et al., 2018). The relationship between frailty and CVD is therefore complex, and is likely to have mutual causality. For example, it is likely that many common cardiovascular conditions drive inflammatory pathway activation, which in turn impacts skeletal muscle and other tissues that drive physical frailty. In addition, chronic inflammatory pathway activation that may stem from biological aging changes and underlying frailty likely also accelerates/worsens clotting states, cardiovascular diseases, and related complications.
Impact of Frailty on Cardiovascular Disease:
Frail adults with CVD typically suffer with worse disease outcomes than those who are not frail (Afilalo, 2014; Veronese et al., 2017). For example, the presence of physical frailty was associated with longer hospital length of stay, increased re-hospitalization, and greater cardiovascular mortality in those with acute myocardial infarction (Erkstad et al., 2011). Similarly, mortality risk was increased three-fold at one year in frail versus non-frail older adults with moderate heart failure (Lupon et al., 2008). Gait speed appears to be a particularly important marker for poor outcomes in cardiovascular disease patients, with risk of mortality increased more than 5-fold comparing gait speeds below versus above WHAT in one study of cardiac surgery patients (Afilalo et al., 2010).
Applying Knowledge of Frailty to Treatment of CVD:
Importantly, physical frailty is also associated with an increased susceptibility to harmful effects from standard therapies for CVD. For example, medical therapy for ischemic heart disease typically includes prolonged antiplatelet therapy, which increases bleeding risk disproportionately in those who are also frail (Alonso et al., 2016).
Current practice reflects concerns by physicians about the tolerability of treatments for CVD in older adults and in particular those who are frail. Several studies have found that those with known frailty were less likely to receive the same extent of therapy as compared to adults without frailty. Physically frail patients were less likely to be admitted to coronary care units and to undergo cardiac catheterization or coronary artery bypass surgery (Damluji et al., 2019). In a 2013 study of patients with atrial fibrillation, frailty was associated with considerably less frequent receipt of evidence-based therapies (Hess et al., 2013). In addition, the use of guideline-directed medical therapy with ACE inhibitor and beta-blockers was lower when frailty was encountered (Sze et al., 2019). It is not known whether medications are tried and not tolerated or never considered because of concern over physical function. For example, fatigue could limit the clinical ability to use beta-blockers to achieve a reduced work-load of the heart as is otherwise indicated. However, denying therapy to older adults is also inappropriate, as early revascularization results in improved clinical outcomes and better symptom control after myocardial infarction regardless of age (Forman et al., 2016).
Research is needed to determine whether the accelerated decline in health among frail older patients with cardiovascular disease could be mitigated by early mobility after procedures, incentive spirometry, physical therapy, and nutritional enrichment. This is an active area with ongoing research trials (Bendayan et al. , 2014; Stammers et al, 2015; NCT03522454).
This reference list supports the text above and provides additional references related to frailty in cardiovascular disease:
- 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.
- Afilalo et al J Am Coll Cardiol. 2010 Nov 9;56(20):1668-76.
- Afilalo J, Lauck S, Kim DH, Lefèvre T, Piazza N, Lachapelle K, Martucci G, Lamy A, Labinaz M, Peterson MD, Arora RC, Noiseux N, Rassi A, Palacios IF, Généreux P, Lindman BR, Asgar AW, Kim CA, Trnkus A, Morais JA, Langlois Y, Rudski LG, Morin JF, Popma JJ, Webb JG and Perrault LP. Frailty in Older Adults Undergoing Aortic Valve Replacement: The FRAILTY-AVR Study. J Am Coll Cardiol. 2017;70:689-700.
- 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
- Damluji AA, Forman DE, van Diepen S, et al. Older Adults in the Cardiac Intensive Care Unit: Factoring Geriatric Syndromes in the Management, Prognosis, and Process of Care: A Scientific Statement From the American Heart Association. Circulation. 2020;141(2):e6-e32. doi:10.1161/CIR.0000000000000741
- Damluji AA, Huang J, Bandeen-Roche K, Forman DE, Gerstenblith G, Moscucci M, Resar JR, Varadhan R, Walston JD and Segal JB. Frailty Among Older Adults With Acute Myocardial Infarction and Outcomes From Percutaneous Coronary Interventions. J Am Heart Assoc. 2019;8:e013686.
- 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.
- 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.
- Ferrucci L and Fabbri E. Inflammageing: chronic inflammation in ageing, cardiovascular disease, and frailty. Nat Rev Cardiol. 2018;15:505-522.
- Forman DE, Alexander K, Brindis RG et al. Improved Cardiovascular Disease Outcomes in Older Adults. F1000Res 2016;5.
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- Hess PL, Kim S, Piccini JP, Allen LA, Ansell JE, Chang P, Freeman JV, Gersh BJ, Kowey PR, Mahaffey KW, Thomas L, Peterson ED and Fonarow GC. Use of evidence-based cardiac prevention therapy among outpatients with atrial fibrillation. Am J Med. 2013;126:625-32.e1.
- 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.
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- Núñez J, Palau P, Sastre C, D'Ascoli G, Ruiz V, Bonanad C, Miñana G, Núñez E and Sanchis J. Sex-differential effect of frailty on long-term mortality in elderly patients after an acute coronary syndrome. Int J Cardiol. 2020; 302:30-33.
- Sze S, Pellicori P, Zhang J, Weston J and Clark AL. Identification of Frailty in Chronic Heart Failure. JACC: Heart Failure. 2019; 7:291.
- 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.