Sian Claire Owen, medical journalist for Cardio Debate, UK

Frailty is increasingly common in elderly patients presenting with cardiovascular disease. With contributing factors such as the ageing population, improved disease survival and more effective treatment for long-term illnesses, this issue is one that requires attention from the medical community.

Although frailty is mostly associated with the elderly, it also affects people suffering from chronic diseases. The American College of Cardiology (ACC) defines frailty as ‘a syndrome characterised by weakness, fatigue and increased vulnerability to physiological stressors’. [1]

A recent position paper from the Acute Cardiovascular Care Association (ACCA) published in the European Heart Journal looks at the latest evidence about managing patients who are frail and who have CVD. [1]

Generally, frailty can be defined using two models: ‘the phenotype model’ where the appropriate intervention can delay or prevent disability, and ‘an accumulated deficit model’ where the disability resulting from frailty has a cumulative effect over time. [2]

Frail patients in general have a higher risk of worse clinical outcomes, and notably frailty is more common in patients with cardiovascular disease. For example, the ACCA review paper states that of patients aged over 65 years receiving percutaneous coronary intervention (PCI) 20% of these exhibited symptoms of frailty. Similarly, 27% of patients aged over 70 years receiving coronary angiography were frail. [2]

The authors also cited that the TaRgeted platelet Inhibition to cLarify the Optimal strategy to medically manage Acute Coronary Syndromes (TRILOGY ACS) trial showed that adding frailty to conventional risk scores, they were able to improve mortality predictions. [3] Furthermore, they also cited a recent systematic meta-analysis which showed that frailty evaluation in a TAVI population helped identify patients who had a greater risk of mortality. Thus assessing frailty as part of the patient clinical characterisation could prove a valuable tool when selecting patients for invasive procedures. [2]

This review paper summarises the evidence that shows which frailty models are appropriate when evaluating patients, and also looks at data which informs the best time for such assessments. However, the consensus is that evaluation of frailty should form part of the pre-assessment of patients in the case of elective CVD procedures. [2]

References

  1. http://www.acc.org/latest-in-cardiology/articles/2016/08/05/08/40/frailty-and-heart-failure
  2. http://journals.sagepub.com/doi/abs/10.1177/2048872618758931?url_ver=Z39.88-2003&rfr_id=ori:rid:crossref.org&rfr_dat=cr_pub%3Dpubmed
  3. White HD, Westerhout CM, Alexander KP, et al. Frailty is associated with worse outcomes in non-ST-segment elevation acute coronary syndromes: Insights from the TaRgeted platelet Inhibition to cLarify the Optimal strategy to medically manage Acute Coronary Syndromes (TRILOGY ACS) trial. Eur Heart J Acute Cardiovasc Care 2016; 5: 251-42.