Cardiovascular Disease

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, 42% in those with acute coronary syndrome , and 37% in those with valvular heart disease.

Introduction:

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: