Physical frailty and long-term mortality in older people with chronic heart failure with preserved and reduced ejection fraction: a retrospective longitudinal study

Abstract

Background: Frailty, a syndrome characterized by a decline in function reserve, is common in older patients with heart failure (HF) and is associated with prognosis. This study aimed to evaluate the impact of frailty on outcomes in older patients with preserved and reduced cardiac function.

Methods: In total, 811 adults aged ≥65 years were consecutively enrolled from 2009 to 2018. HF was diagnosed according to the ICD9 code and a 2D echocardiogram was categorized by reduced ejection fraction (HFrEF) and preserved ejection fraction (HFpEF). The index date was registered at the time of HF. All patients received a comprehensive geriatric assessment, and clinical outcomes were examined with adjustment of the other prognostic variables.

Results: Mean age was 80.5 ± 7.1 years. The prevalence of HF, HFpEF, HFrEF, Fried, and Rockwood frailty indicators was 28.5, 10.4, 9.7, 52.5, and 74.9%, respectively. At baseline, scores in the Timed Up and Go test was closely associated with the severity of HF, either with HFpEF or HFrEF. After a mean follow-up of 3.2 ± 2.0 years, we found that HF patients with low handgrip strength (HGS) had the poorest survival, followed by non-HF patients with decreased HGS, and HF with fair HGS in comparison with non-HF with fair HGS (p = 0.008) if participants were arbitrarily divided into two HGS groups. In all patients, a high Rockwood frailty index was independently associated with increased mortality (adjusted hazard ratio [aHR] = 1.05; 95% confidence interval [CI]: 1.0004 to 1.10). In addition, the adjusted mortality HR was 3.42 with decreased HGS (95% CI: 1.03 to 11.40), 7.65 with use of mineralocorticoid receptor antagonist (95% CI: 2.22 to 26.32), and 1.26 with associated multi-comorbidities assessed by Charlson comorbidity index (95% CI: 1.05 to 1.51).

Conclusions: Our study results indicate that frailty and decreased physical functions were associated with HF. Besides, frailty and HGS predicted prognosis in the patients, and there was a combined effect of HF and low HGS on survival.

Keywords: All-cause mortality; Charlson comorbidity index; Function reserve; Handgrip strength; Heart failure; Timed up and go test.

Fig. 1

Flowchart presenting the selected participants. 151 patients had heart failure (HF), and 660 subjects had non-HF. Abbreviations: MNA-SF mini-nutritional assessment-short form; TUG timed up and go test; HGS handgrip strength; 6 MW 6-m walking

Fig. 2

Physical functionality and heart failure (HF) with and without reduced ejection fraction (EF). (a,b) Representative image of Timed Up and Go (TUG) between HF and non-HF. (c,d) TUG among non-HF, HFpEF, and HFrEF. (e,f) Handgrip strength (HGS) between HF and non-HF. (g,h) HGS among non-HF, HFpEF, and HFrEF. (i,j) 6-m walking (6 MW) between HF and non-HF. (k,l) 6 MW among non-HF, HFpEF, and HFrEF. TUG values were divided into fifths both in men and women. HGS values were separated into tertiles both in men and women. 6 MW values were calculated into deciles with a cut-off point of 25 s in men and eight equal parts with a cut-off point of 23 s in women

Fig. 3

Kaplan-Meier survival curves for mortality stratified by the different levels of handgrip strength, heart failure (HF), and non-HF