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. 2026 Aug 3;12:e19. doi: 10.15420/cfr.2025.48

Multidimensional and Multidisciplinary Management of Heart Failure Patients with Frailty

Cristiana Vitale 1,2, Gabriele Fragasso 3, Izabella Uchmanowicz 4, Angela Sciacqua 5, Pablo Díez-Villanueva 6, Shirley Sze 7, Quin E Denfeld 8, Markus S Anker 9,10,11,12, Elena Marques-Sule 13, Anna Strömberg 14, Emanuelle Berthelot 15,16, Stephan von Haehling 17,18, Giuseppe Rosano 1,2, Wolfram Doehner 19,20,21,22, Yuhui Zhang 23, Camilla Hage 24,25,✉
PMCID: PMC13458406  PMID: 42582854

Abstract

This paper discusses the considerations for multidimensional and multidisciplinary management of heart failure (HF) patients with frailty. Frailty is a multidimensional, dynamic and potentially reversible state, defined by clinical, functional, psycho-cognitive and social domains. Frailty is seldom systematically assessed in clinical practice in HF patients. Paradoxically, although the absolute benefit of HF guideline-directed medical treatment in frail HF patients seems greater, it is under-prescribed. This therapeutic gap could be related to different reasons, such as concerns about safety, polypharmacy and the lack of specific evidence-based data. Frail HF patients require a comprehensive, multidimensional therapeutic strategy that integrates available evidence-based pharmacological interventions with targeted non-pharmacological modalities across multiple clinical disciplines to optimise patient outcomes. The four domains of frailty should be objectively and routinely assessed with a multidimensional approach to facilitate a more individualised and comprehensive care plan delivered by a multidisciplinary team. In the future, we need more dedicated studies and randomised clinical trials that include frail HF patients.

Keywords: Frailty, heart failure, guideline-directed medical treatment, outcomes, multidimensional, multidisciplinary

In patients with heart failure (HF), frailty is a multidimensional, dynamic and potentially reversible state, defined by four cardinal domains: clinical, functional, psycho-cognitive, and social (Figure 1).1 Frailty and HF are intertwined clinical syndromes, both characterised by multi-system involvement and carrying profound implications for patient management.

Figure 1: Multidimensional and Multidisciplinary Management of the Four Cardinal Domains of Frailty in Heart Failure.

Figure 1:

HF = heart failure. Created using images from iStock.

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Frailty is present in nearly 45% of HF patients, in whom it is associated with negative clinical outcomes, including poor health-related quality of life and higher risk of HF hospitalisation and death, compared with non-frail patients.2–6 Of interest, not only the physical component of frailty but also psycho-social factors, including depression or anxiety, cognitive impairment and social isolation and/or loneliness are all strongly associated with negative outcomes in HF patients with frailty.7,8

Despite the high prevalence of frailty, its established prognostic role and its impact on decision-making, frailty assessment remains underutilised in clinical practice. More than 60 instruments are available to evaluate frailty in clinical practice. Among these, the Fried frailty phenotype, the Frailty Index and the Clinical Frailty Scale are the most commonly used instruments in HF patients (Supplementary Table 1).1,9–12 There are also instruments to assess components in the four domains of frailty (Supplementary Table 2).10,12–31 However, given that each instrument has advantages and limitations, no gold standard is currently available to assess HF patients, in whom cardiac symptoms usually overlap with manifestations of frailty. Given the complex interactions between cardiac dysfunction and different frailty components, and their impact on adverse outcomes and management, a multidimensional approach, despite being more time-consuming, may be more appropriate for frailty assessment and individualised care planning in HF patients.32

Recently, the Heart Failure Frailty Score (HFFS), a practical, rapid and easy-to-perform multidimensional assessment, specifically designed to comprehensively evaluate the four main domains of frailty in HF patients, was developed (Figure 1 and Supplementary Table 1).1 However, prospective validation of the HFFS is required to establish its prognostic utility.

The aim of this paper is to provide practical guidance for clinicians managing HF patients who are identified as frail and to outline the key principles for a multidimensional and multidisciplinary approach to their care.

Therapeutic Options

Comprehensive, multidimensional therapeutic strategies, integrating evidence-based pharmacological interventions with non-pharmacological modalities, such as structured exercise training programmes, nutritional support, cognitive behavioural therapy and social support systems, should be adopted to treat HF patients with frailty. This strategy, targeting both HF and all main frailty domains, can potentially provide a synergistic care model, tailored to individual patient needs. However, evidence that this approach translates into optimised patient outcomes is still lacking.

Pharmacological Interventions

In patients with HF with reduced ejection fraction (HFrEF), the ‘four pillars’ (renin–angiotensin–aldosterone system inhibitors/angiotensin receptor–neprilysin inhibitors [RAASI/ARNI], β-blockers, mineralocorticoid receptor antagonists [MRAs] and sodium-glucose cotransporter 2 inhibitors [SGLT2I]) of guideline-directed medical treatment (GDMT) have been demonstrated to successfully reduce mortality and HF hospitalisation, and also improve functional capacity and health-related quality of life.33,34

The treatment options are more limited in patients with HF and left ventricular ejection fraction (LVEF) >40%, i.e. HF with preserved or mildly reduced LVEF (HFpEF/HFmrEF). GDMT consists of an SGLT2I added to a diuretic for decongestion alongside the treatment of comorbidities. Novel MRAs have been shown to reduce mortality and HF hospitalisations in clinical trials, but a recommendation for use is not yet included in guidelines.35,36 Additionally, in obese HFpEF/HFmrEF patients, glucagon-like peptide-1 receptor agonists and glucose-dependent insulinotropic polypeptide represent potential novel options.37,38

The presence of frailty consistently emerges as a key factor associated with both under-prescription and sub-optimal dosing of GDMT, irrespective of LVEF.39 In patients with HFrEF hospitalised for acute decompensated HF, physical frailty (Cardiovascular Health Study [J-CHS] criteria) is associated with nearly sevenfold increased odds of non-optimised therapy compared with non-frail patients, regardless of age and comorbidities, such as renal dysfunction.40

In contrast, evidence supports the protective role of GDMT in HF patients with frailty.41 For example, the use of combination therapy with RAASI, β-blockers and MRAs reduced the risk of 2-year all-cause hospitalisation across frailty groups (multimorbidity frailty index derived from ICD-10 codes), in hospitalised HF patients in Taiwan’s National Health Insurance Research Database.42 Furthermore, physical frailty (J-CHS) did not modify the beneficial prognostic impact of RAASI and β-blockers in hospitalised Japanese HFrEF patients, indicating that patients with frailty also benefit from these medications.43 Dapagliflozin demonstrated consistent beneficial effect on the combined endpoint of worsening of HF and cardiovascular death, regardless of frailty status (Rockwood frailty index [FI]), with the greatest improvements in symptoms, physical function and health-related quality of life observed in HF patients with the greatest level of frailty, as demonstrated in post-hoc sub-analyses of the DELIVER and DAPA-HF studies.44,45

The effect of spironolactone on cardiovascular death or HF hospitalisation was not attenuated by frailty status (Rockwood FI) in HFpEF patients, in a post-hoc analysis of TOPCAT Americas.46 Similarly, sacubitril/valsartan demonstrated greater reduction in the composite endpoints of total HF hospitalisations or cardiovascular death compared with valsartan in the frailest group (Rockwood FI) of HFpEF patients (55%), in a post-hoc sub-analysis of the Paragon-HF trial.47 Recently, in a pre-specified secondary analysis of the FINEARTS-HF trial, finerenone improved symptoms and reduced the combined endpoint of total worsening HF events and cardiovascular death, in patients with frailty (Rockwood FI). Additionally, the adverse effects of finerenone on hypotension, elevated creatinine concentration, hyperkalaemia, or hypokalaemia were not modified by frailty status.48

While these results offer valuable clinical insights, dedicated trials are needed to confirm the findings. Clinical challenges in daily practice often prevent healthcare professionals from optimising GDMT in these vulnerable populations. Non-selective β-blockers can exacerbate fatigue, weakness and hypotension, symptoms that are already common concerns in HF patients with frailty.49 Additionally, data from the PURSUIT-HFpEF registry showed that β-blocker use was significantly associated with worse prognosis specifically in patients with high frailty scores (Clinical Frailty Scale) but not in those with low frailty.50

Diuretics are indicated to alleviate congestion, although they may contribute to muscle wasting and increase the risk of dehydration, orthostatic hypotension and electrolyte imbalances.51 Furthermore, the enhanced diuresis associated with these agents may limit patient mobility and involvement in social activities, potentially accelerating functional decline, depression and social isolation. The concomitant use of diuretics and RAASI requires a delicate balance between achieving therapeutic benefit and avoiding harmful complications, such as worsening of renal function, hypotension, electrolytes imbalance and increased risk of falls.52

Polypharmacy, multimorbidity and a higher risk of drug–drug and disease–drug interactions represent additional constraints for using GDMT in daily clinical practice. However, rather than preventing the prescription of beneficial GDMT, these challenges should encourage systematic medication review and discontinuation of harmful drugs. Medications that negatively affect cognition and/or mobility, those that increase the risk of falls (e.g. sedating agents, anticholinergic drugs, psychoactive substances, peripheral α1-blockers) or those that can worsen HF (e.g. non-steroidal anti-inflammatory drugs, calcium channel blockers) should be discontinued (deprescribing) when possible. Tools such as the Beers Criteria and the STOPP/START criteria can aid healthcare professionals to identify potentially inappropriate medications and optimise pharmacotherapy, especially in older people.53,54

A personalised approach aimed at reaching the maximum individual tolerated dose represents a pragmatic therapeutic strategy, incorporating slower dose escalation and extended monitoring periods. However, these extended monitoring requirements may be challenging in HF patients with frailty due to functional limitations, transportation issues or psycho-cognitive impairment that may prevent regular face-to-face appointments. Telemonitoring, virtual appointments, telephone follow-up, medical transportation assistance, or enhanced caregiver involvement could address these barriers.

Invasive Procedures in Patients with Advanced Heart Failure

In patients with advanced HF who are candidates for interventional procedures such as myocardial revascularisation, CRT, left ventricular assist device (LVAD) implantation, transcatheter edge-to-edge mitral valve repair, transcatheter aortic valve implantation and heart transplantation, frailty assessment can support patient selection by identifying suitable candidates most likely to benefit from these interventions versus those at increased risk of futility or adverse outcomes. Chronological age is often incorrectly used as a surrogate marker of frailty, and robust evidence regarding the efficacy and safety of invasive procedures in HF patients stratified by frailty status is still lacking.

In patients with advanced HF and frailty (Rockwood FI), cardiac implantable devices were not associated with reduced all-cause death.55 In the COMFFORT Study, frailty (Fried frailty phenotype) was a strong predictor of non-arrhythmic death in ICD–CRT-D recipients.56

LVADs are increasingly implanted as destination therapy (DT) for advanced HF patients who are ineligible for heart transplant due to comorbidity or advanced age.57 While preoperative frailty is associated with rehospitalisation and increased risk of death, LVAD implantation or heart transplantation improved and reversed frailty in older adults with advanced HF surviving these procedures, demonstrating that frailty is dynamic.58

Two hypothetical aetiologies of frailty relevant to the DT LVAD population have been proposed: ‘LVAD-responsive frailty’ (i.e. resulting directly from HF) and ‘LVAD-independent frailty’ (i.e. resulting from non-HF comorbidities).59

An ideal frailty measure for LVAD candidates not only quantifies the degree of frailty but also distinguishes LVAD-responsive frailty from LVAD-independent frailty, also enhancing the clinician’s ability to identify patients who would receive the most benefit from DT LVAD. Therefore, the International Society for Heart Lung Transplantation listing criteria recommend frailty assessment in all patients being evaluated for advanced therapy, such as LVAD implantation or heart transplantation.59

Non-pharmacological Interventions in Heart Failure and Frailty

Nutrition Interventions

In patients with HF, malnutrition is closely linked with frailty, being simultaneously an aetiological factor and a clinical parameter of frailty. Therefore, routine screening for malnutrition is recommended, using validated tools such as the Mini Nutritional Assessment.60 Nutritional interventions could be beneficial because they regulate body weight, glucose–insulin homeostasis, and enhance muscle protein synthesis and anabolism.2,61 However, there is a lack of clear evidence of specific diet regimens as a strategy to improve the frailty status of HF patients. Adequate protein consumption can help prevent loss of lean muscle mass, especially in patients with poor appetite or suboptimal caloric intake.62 However, protein consumption should be individualised based on other comorbidities, such as chronic kidney disease, which may require dietary modifications.63 Tailored care plans and close monitoring for signs of protein-energy wasting and sarcopenia progression, as well as renal function, should be mandatory.64

Sarcopenia, defined as loss of muscle strength, muscle quantity and/or quality and physical performance, as an indicator of severity, is very common in HF patients with frailty, especially in the elderly.65 Sarcopenia should therefore be regularly evaluated through measurements of muscle mass and strength and physical performance.65

Fluid and salt (sodium) restrictions are commonly recommended in HF patients, despite limited or no evidence.66–68 In HF patients with frailty (particularly those who are older, or have reduced thirst perception, lower total body water, kidney impairment or polypharmacy), these restrictions require additional caution, due to the higher risk of hypotension, renal dysfunction, falls, delirium and reduced drug tolerance (e.g. to diuretics, RAASI). These restrictions can also compromise the intake of adequate oral nutrition, particularly when liquid calories, such as soups and oral supplements, represent a significant portion of the patient’s dietary intake. Furthermore, they can negatively affect quality of life, causing thirst and discomfort, reduce enjoyment of meals and increase caregiver burden. Balancing fluid intake with medications, including diuretics, should be carefully monitored in HF patients with frailty. Regular volume assessment and weight monitoring should be promoted, focusing not only on weight gain but also on inappropriate weight loss, given that both can signal clinical deterioration. Dietary monotony, sodium restriction, diminished appetite, early satiety after consuming small quantities of food, and depression can negatively influence food intake patterns and should be systematically addressed by the multidisciplinary team in these vulnerable patients. Promoting a varied and balanced diet that considers texture modification for swallowing or dental problems, and smaller, frequent meals for early satiety, may help ensure an adequate food intake and improve patient nutritional status.69

Exercise

Exercise represents one of the few interventions that simultaneously improves quality of life, enhances exercise capacity and helps prevent and overcome frailty-related health burden in HF patients.70 The 2021 European Society of Cardiology HF guidelines recommend that supervised, exercise-based cardiac rehabilitation programmes should be considered in HF patients with frailty, with a class 2a level of evidence.34 Exercise could offer potential multi-system benefits across all four main domains of frailty and HF management (Table 1).32

Table 1: Multidimensional Benefits of Exercise in Heart Failure Patients with Frailty.
Domain Level Benefits Mechanisms
Clinical Cardiovascular Improved exercise tolerance and functional capacity Enhanced cardiac output, peripheral oxygen extraction, left ventricular function, endothelial dysfunction, and reduced resting heart rate
Muscular/skeletal Increased muscle strength and mass Counteracts sarcopenia, improves protein synthesis
Improved bone density Mechanical loading, improved calcium metabolism
Improved balance and coordination Enhanced proprioception, reduced fall risk
Metabolic Enhanced glucose and lipid metabolism Improved insulin sensitivity, glycaemic control, reduced triglycerides, increased HDL cholesterol
Improved appetite and nutrition Increased energy expenditure, improved digestive function
Respiratory Improved ventilatory efficiency Enhanced oxygen uptake, reduced ventilation–perfusion mismatch
Reduced dyspnoea Better respiratory muscle strength, improved gas exchange
Functional Mobility Improved functional independence Improved mobility, reduces fear of falls
Psycho-cognitive Neurological Reduced depression and anxiety Enhanced endorphin release, improves self-efficacy
Improved cognitive function Improved cerebral blood flow, neuroprotective effects
Increased confidence Improved self-perception
Social Reduced social isolation Peer support networks, group exercise programmes
Improved functional independence Enhances activities of daily living performance
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A reduction in frailty and an improvement in physical function following exercise rehabilitation have been reported in HF patients.71,72 In chronic stable HFrEF patients, the frailty burden (Rockwood FI) can modify the treatment effect of a supervised aerobic exercise programme, as shown by a post-hoc analysis of the HF-ACTION trial; in fact, patients with higher frailty burden at baseline had a greater reduction in the risk of the primary composite endpoint than non-frail patients, largely driven by a reduction in all-cause hospitalisation.73 However, most of the studies exploring the effects of exercise in patients with HF have failed to differentiate patients with frailty, or to include specific frailty assessments.

Clinicians should not be hesitant to start physical exercise in HF patients with frailty, but the exercise programme should be individualised and adapted as needed.74 A multicomponent exercise training programme, which includes aerobic, strength and balance–flexibility exercises, theoretically could be the most effective programme to address HF and all the components of frailty. Adults identified as frail are recommended to complete aerobic exercise, followed by balance–flexibility exercise and resistance training.75 Resistance training exercises can generally be added within 2–4 weeks of starting the aerobic exercise programme or sooner according to clinical judgement.75

This multicomponent rehabilitation programme, including aerobic, resistance, balance training and mobility, beginning early after hospital admission for acute HF, is feasible and safe, and resulted in improved physical function, frailty, quality of life and depression.76–79 A multicomponent exercise framework of 45 minutes, ideally three times per week, consisting of aerobic (20 minutes), resistance (10 minutes) and balance–flexibility (15 minutes) training, has been proposed for frail older adults.77 However, in HF patients with frailty, this scheme should be implemented gradually with initial modifications in frequency, duration and intensity based on individual functional capacity and cardiovascular tolerance, ideally in a supervised cardiac rehabilitation setting.

Training could either begin with low-intensity seated activities or trainer-supported activities, such as 5–10 minutes of walking or chair-based exercises, 2–3 times weekly, emphasising short intervals, adequate rest, realistic goals, symptom monitoring and control, with stepwise progression as tolerated by patients. In patients with severe mobility limitations, or other disabilities, a pragmatic approach is to start with bed-based resistance exercises targeting major muscle groups, progressively advancing to more complex activities as functional capacity improves.

Programmes combining physical exercise with cognitive training show synergistic benefits for cognitive function, mental health and physical frailty reduction.80,81 Further implementation of rehabilitation in the preoperative state has been shown to reduce frailty scores in patients with advanced HF.82

It is important to acknowledge that not all patients are willing or able to attend regular supervised exercise programmes. Barriers may include personal preference, lack of transportation, or limited availability of programmes in more rural areas. Therefore, feasible home-based exercise programmes should be provided to patients at hospital discharge.83 Non-supervised exercise programmes can offer benefits for HF patients, as shown by the REACH-HF trial, but data on HF patients with frailty are lacking. Thus, non-supervised home-based exercise in HF patients with frailty raises important safety concerns and requires careful patient selection. Patients with severe frailty, recent cardiac decompensation, cognitive impairment, or poor symptom awareness are not appropriate candidates. Essential safety measures include simplified home-based protocols (chair exercise, short walking intervals, light resistance activities), regular remote follow-up, clear instructions on when to stop exercising or seek medical help, and family or caregiver involvement.84

Psycho-cognitive Interventions

Cognitive and mental health play a crucial role in the holistic management of HF patients with frailty. In these patients, cognitive impairment and depression are common and are associated with worse outcomes, including higher mortality and rehospitalisation rates.85–90

In HF patients, depression and frailty interact synergistically, through a bidirectional relationship. Depression accelerates frailty and HF progression, potentially via reduced motivation for physical activity, poor nutritional intake, social withdrawal, and poor medication and self-care adherence.88,91–93 Also, frailty and HF increase vulnerability to depressive symptoms through functional decline, loss of independence and diminished quality of life.94 Mentally stimulating activities, such as music therapy, creative arts and structured social interactions, can support cognitive function and emotional well-being, particularly in socially isolated or cognitively vulnerable patients.95 These activities may be helpful given that antidepressive pharmacological treatments have not improved outcomes in HF patients.80,96 However, evidence is lacking on the specific effect of psycho-cognitive interventions and antidepressive pharmacological treatments in HF patients with frailty.

Social Interventions

Social isolation and limited support systems negatively impact both psychological health and clinical outcomes in HF patients with frailty.7,8 Improved social interaction and structured support programmes (e.g. group-based physical or cognitive activities), volunteer programmes and community centres can increase treatment adherence and improve quality of life and functional status in HF patients with frailty.97,98

The OPERA-HF study emphasised that patients with lower perceived social support had higher readmission and mortality rates, highlighting the strong prognostic role of social frailty.7 Peer support groups and social clubs can reduce loneliness and offer emotional and practical support, contributing to both psychosocial stability and clinical improvement. Therefore, social interventions should be systematically integrated into clinical management, as indispensable components of multidimensional care for HF patients with frailty.

Self-care

HF self-care refers to the actions and behaviours that patients with HF undertake to manage their condition and maintain and promote physical and mental health.99 This includes adhering to prescribed medications, monitoring symptoms, engaging in appropriate physical activity, and seeking medical attention when necessary. Effective self-care reduces hospitalisations, improves survival and enhances overall well-being.88 Frailty may impair self-care behaviours because it affects physical, cognitive and psychosocial domains.100 Specifically, cognitive impairment and depression diminish decision-making and self-reflective abilities, both crucial components for effective self-care. Together with physical function impairment, poor self-care may further limit treatment adherence and reduce the engagement in cardiac rehabilitation training or other social activities. Multicomponent self-care interventions, including tailored exercise, nutritional support and behavioural strategies, could potentially improve self-care capabilities in HF patients, including those with frailty. However, to date there are no self-care studies that have adequately incorporated frailty-specific assessment tools, and the results of the PRISM-HF study could clarify this assumption.92

Palliative Care

Numerous HF guidelines and statements advocate for the provision of palliative care alongside HF care and this seems to be imperative for those patients with frailty.64,101 HF patients with frailty present a higher prevalence of diminished physiological reserve across the cardinal domains of frailty, coupled with multimorbidity, polypharmacy, and recurrent decompensations necessitating hospitalisation. This complex phenotypic constellation substantially diminishes health-related quality of life and imposes considerable caregiver burden.

Therefore, in these patients, a palliative care approach addressing physical, psychological, social and spiritual needs throughout the illness should not be considered as the end-stage of life and should be integrated early in the management of HF patients with frailty and periodically re-evaluated.102,103

Goals-of-care discussions should encompass symptom-directed management strategies, patterns of recurrent hospitalisation despite GDMT, progressive functional deterioration, ethical considerations regarding device-based interventions in severely frail patients, as well as comprehensive caregiver support mechanisms.102 Specialised palliative care consultation should include shared decision-making frameworks that elucidate patient values and preferences, establish realistic prognostic expectations regarding therapeutic benefits and treatment-associated burdens, and ensure goal-concordant care delivery, particularly when therapeutic objectives transition toward comfort-focused interventions and symptom palliation.

For patients with HF and an ICD or LVAD, palliative care involvement facilitates anticipatory guidance regarding potential future decisions about device de-escalation or withdrawal when treatment no longer aligns with patient goals or quality of life priorities. Such preference-sensitive decisions require structured shared decision-making, particularly in high-acuity cardiovascular settings, where patients often face trade-offs between survival, symptom burden and functional outcomes.104,105 Advance care planning, including deliberation of preferences for life-sustaining interventions, should be initiated early in the disease trajectory and revisited iteratively as frailty severity evolves.106

Equally paramount is systematic assessment of caregiver burden, given that HF patients with frailty are substantially dependent on family caregivers, who experience significant physical, psychological and socioeconomic strain. Consequently, comprehensive management paradigms should incorporate regular caregiver burden assessment, structured educational interventions, respite care services, and anticipatory guidance regarding disease trajectory and progression.

Multidisciplinary Team-based Management of Frailty in Heart Failure

HF patients with frailty have multi-system impairments, including diminished physiological reserves and impaired coping mechanisms, skeletal muscle weakening, functional deficits, dietary inadequacy, cognitive decline and psycho-social vulnerability (i.e. depression, anxiety, social isolation).107 The use of single-domain frailty terms (such as physical, cognitive, social, or psychological frailty) should be avoided, because these multi-system impairments do not occur independently, but present profound interactions and reciprocal influences in affected individuals.

For example, physical or cognitive limitations may precipitate social isolation; psychological distress diminishes motivation for physical activity and social participation; and social frailty exacerbates depression while accelerating functional decline. Deficits in one domain frequently potentiate vulnerability in others, creating cascading effects that amplify overall frailty burden and complicate the clinical trajectory.

Frailty evaluation may assist healthcare professionals in the development of individualised care plans. Until a gold standard instrument to assess frailty in the HF population is established, a pragmatic operational approach to evaluate the multidimensional aspects of frailty in busy clinical practice could be to first use a validated physical frailty scale (Figure 2) and then, a domain-specific instrument to assess the presence of other frailty contributors (Supplementary Table 2).

Figure 2: Management Flow Chart for Heart Failure Patients with Frailty.

Figure 2:

BDI = Beck Depression Inventory; GDMT = guideline-directed medical treatment; HF = heart failure; MMSE = Mini-Mental State Examination; MoCA = Montreal Cognitive Assessment; PHQ = Patient Health Questionnaire; UCLA = University of California, Los Angeles.

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When frailty is identified, the optimal management of these high-risk and complex patients requires a multidisciplinary team, including physicians with different specialities, clinical pharmacists, dietitians, physiotherapists, occupational therapists, social workers and specialised nurses (Figure 3), whose synergistic collaboration can potentially translate into multiple substantial benefits (Table 2) and better outcomes for this high-risk population.88,91,93,107

Figure 3: Multidisciplinary Team-based Management of Frailty in Heart Failure.

Figure 3:

HF = heart failure. Created using images from iStock.

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Table 2: Translation of Theory into Clinical Practice: Key Aspects.

Multidimensional Frailty Assessment
Goal: mandatory early identification of frailty
A structured multidimensional frailty score should be routinely integrated into clinical practice to define an individualised care plan and to establish a baseline assessment for longitudinal comparison.
Optimise GDMT
Goal: avoidance of undertreatment of frail patients:

  • SGLT2I should be used in all HF patients; MRA considered in HFpEF patients and ACEI/ARB/ARNI, β-blockers and MRA in HFrEF patients

  • Better to ‘start low and go slow’ than not to start GDMT

  • Frequent medication review, medication reconciliation, adherence and side-effect monitoring in-person or telehealth

Evaluate Invasive Procedures Individually
Goal: avoidance of automatic exclusion of frail patients from interventions:

  • Multidimensional approach: to evaluate risks versus potential quality-of-life gains

  • Shared decision-making: discuss goals of care, preferences and realistic outcomes with patient and family

  • Promote nutrition, functional and psychological support and involve family/caregiver to improve outcomes

Continuous Monitoring and Re-evaluation
Goal: ongoing monitoring because frailty and HF both fluctuate

  • Set a re-evaluation interval according to the different setting and the severity of both HF and frailty

  • Digital tools: remote monitoring apps or wearable devices for early detection of decline

Multidisciplinary Team Management
Goal: integration of all specialties into a cohesive care plan including a multidisciplinary team (Figure 3):

  • Regular multidisciplinary team meetings (virtual or in person)

  • Shared care plans and documentation accessible to all team members

  • Patient and caregiver education sessions
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ACEI = angiotensin-converting enzyme inhibitor; ARB = angiotensin II receptor blocker; ARNI = angiotensin receptor–neprilysin inhibitor; GDMT = guideline-directed medical treatment; HF = heart failure; HFpEF = HF with preserved ejection fraction; HFrEF = HF with reduced ejection fraction; MRA = mineralocorticoid receptor antagonist; SGLT2I = sodium–glucose cotransporter 2 inhibitor.

In order to implement this multidimensional model effectively in daily practice, fundamental changes to the current healthcare systems and healthcare training are imperative to move beyond the traditional disease-specific approach to patient-centred integrated care models.108 The capacity to share information across disciplines, via electronic health records, enhanced by artificial intelligence-assisted decision support, is an essential prerequisite to facilitate communication and coordination between multiple specialists and avoid care fragmentation.

Specific training programmes promoting collaboration skills among healthcare professionals, emphasising multidisciplinary competency, defining standardised protocols for multidisciplinary care planning and clear roles and responsibilities within multidisciplinary teams are highly warranted. Furthermore, to optimise outcomes for HF patients with frailty, it is essential to integrate patient and caregiver perspectives into care planning and to develop robust community-based support networks that ensure care continuity beyond the hospital setting. Indeed, when feasible, patients and caregivers should be empowered to take an active role in monitoring, also through the support of digital health tools, remote monitoring devices, and structured education programmes.

Telemedicine and remote home-based telemonitoring have significant potential to monitor the dynamic nature of both HF and frailty, and reduce HF events and healthcare costs.109 Frail patients who received an eHealth-based follow-up had a lower incidence of new HF events than the least frail patients in standard HF care.109 Although implementation of telemedicine for HF patients with frailty often faces well-recognised barriers (i.e. limited digital literacy, inadequate access to devices, particularly in socio-economically disadvantaged or rural populations, or cognitive impairment that may hinder independent technology use), telemedicine represents a valuable tool for maintaining continuity of care and supporting earlier detection of clinical instability in HF patients with frailty.

Conclusion

Frailty is a dynamic state, and it is potentially reversible. After careful multidimensional assessment of frailty, healthcare professionals should evaluate GDMT and invasive procedures when appropriate, given that this vulnerable population can potentially benefit the most in terms of functional capacity, quality of life and survival from optimal treatment, due to their higher absolute risk. Continuous monitoring and periodic re-evaluation of frailty are critical elements of the personalised and multidimensional care plan due to the dynamic nature of both HF and frailty. Multidisciplinary team management of the HF patient with frailty should be the rule rather than the exception.

Clinical Perspective

  • Frailty is highly prevalent in heart failure (HF) patients with common pathophysiological mechanisms and has a significant impact on clinical and patient-reported outcomes.

  • In HF patients with frailty, under-prescription and suboptimal dosing of guideline-directed medical treatment (GDMT) is common, although they have a higher baseline risk for adverse HF events and may receive a relatively greater benefit from GDMT than their non-frail counterparts.

  • Interventions should include nutrition, exercise, psycho-social and self-care to improve outcomes in patients with HF and frailty.

  • A multidisciplinary and individualised plan of care is essential in the management of HF patients with frailty.

  • There is a lack of evidence-based data and dedicated studies and trials that include patients with frailty are highly warranted.

Supplementary Materials

Supplementary Table 1. Most commonly used instruments to assess frailty in patients with HF. Time requirements are intended as the average time needed to perform the test but do no consider the time needed to explain how to perform the test to the patient. The time needed can also be influenced by the experience of the sta? performing the test.
cfr-12-e19_supp.pdf (174KB, pdf)

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Associated Data

This section collects any data citations, data availability statements, or supplementary materials included in this article.

Supplementary Materials

Supplementary Table 1. Most commonly used instruments to assess frailty in patients with HF. Time requirements are intended as the average time needed to perform the test but do no consider the time needed to explain how to perform the test to the patient. The time needed can also be influenced by the experience of the sta? performing the test.
cfr-12-e19_supp.pdf (174KB, pdf)

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