Cognitive impairment improves the predictive validity of physical frailty for mortality in patients with advanced heart failure referred for heart transplantation

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Background

The aim of this study was to identify whether the addition of cognitive impairment, depression, or both, to the assessment of physical frailty provides better outcome prediction in patients with advanced heart failure referred for heart transplantation (HT).

Methods

Beginning in March 2013, all patients with advanced heart failure referred to our Transplant Unit have undergone a physical frailty assessment using the Fried frailty phenotype. Cognition was assessed with the Montreal Cognitive Assessment and depression with the Depression in Medical Illness questionnaire. We assessed the value of 4 composite frailty measures: physical frailty (PF ≥ 3 of 5 = frailty), “cognitive frailty” (CogF ≥ 3 of 6 = frail), “depressive frailty” (DepF ≥ 3 of 6 = frail), and “cognitive-depressive frailty” (ComF ≥ 3 of 7 = frail) in predicting outcomes.

Results

Frailty was assessed in 156 patients (109 men, 47 women), aged 53 ± 13 years, and with a left ventricular ejection fraction of 27% ± 14%. Inclusion of cognitive impairment or depression in the definition of frailty increased the proportion classified as frail from 33% using PF to 42% using ComF. During follow-up, 28 patients died before ventricular assist device implantation or HT. Frailty was associated with significantly lower ventricular assist device- and HT-free survival, with CogF best capturing early mortality: 12-month survival for non-frail and frail cohorts was 81% ± 5% vs 58% ± 10% (p < 0.02) using PF and 85% ± 5% vs 56% ± 9% (p < 0.002) using CogF. Combining the Depression in Medical Illness score with PF or CogF did not strengthen the relationship between frailty and mortality.

Conclusions

The addition of cognitive impairment to the assessment of PF strengthened its capacity to identify advanced heart failure patients referred for HT who are at high risk of early death.

Section snippets

Methods

The St Vincent’s Hospital Research Ethics Committee reviewed and approved this study (HREC Reference number LNR/13/SVH/21). Informed consent was obtained from all patients for their data to be entered prospectively into a dedicated database for subsequent analysis.

Prevalence of frailty

Frailty was assessed in 156 patients (109 men and 47 women; age 53 ± 13 years, range 16–73 years; LVEF 27% ± 14%) as part of their transplant referral work-up. Of these, 108 were accepted for transplantation, 22 were considered too well, and 26 were determined to be medically unsuitable. The underlying causes of heart failure were dilated cardiomyopathy (55%), ischemic heart disease (26%), hypertrophic or restrictive cardiomyopathy (13%), and other cardiac diseases (6%).

Baseline characteristics

Discussion

There is ongoing debate regarding the concept of frailty as a multidimensional syndrome of accumulated deficits spanning physical, psychosocial, and functional domains as opposed to a unidimensional syndrome based on a physical-biologic phenotype.15 This has led to 2 fundamental definitions from which most working measures of frailty have evolved: the frailty phenotype proposed by Fried et al 7 and the Rockwood Frailty Index.16, 17 The frailty phenotype proposed by Fried et al involves the

Disclosure statement

None of the authors has a financial relationship with a commercial entity that has an interest in the subject of the presented manuscript or other conflicts of interest to disclose.

References (21)

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