Table 1:
Best evidence papers
| Author, date, journal and country Study type (level of evidence: USPSTFQR score) |
Patient group | Outcomes | Key results | Comments |
|---|---|---|---|---|
| Afilalo et al. (2010), J Am Coll Cardiol, USA/Canada [4] Multicentre prospective cohort study (fair quality) |
131 patients aged 70 or older undergoing elective CABG and/or valve replacement/repair Mean age 75.8 ± 4.4 years M:F–87:44 Frailty defined by slow walking speed <6 m in 5 s (n = 60) Fit by normal walking speed >6 m in 5 s (n = 71) |
Composite 30-day mortality or major morbidity | Slow gait increase risk 9 of 71 fit vs 21 of 60 frail (P = 0.002) OR 3.17 (95% CI 1.17–8.59) AUC 0.74 (0.64–0.84) STS score with gait speed added vs 0.7 (0.6–0.8) STS alone; IDI 5% (95% CI 1–8%) |
There was no correlation between gait speed and STS score, suggesting that these were representing distinct domains Slow gait speed conferred a 2- to 3-fold increase in risk for any level of STS-predicted mortality or major morbidity compared with normal gait speed |
| 30-day mortality | 1 of 71 fit vs 6 of 60 frail (P = 0.047) |
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| Length of stay (still in hospital at 14 days) |
13 of 71 fit vs 21 of 60 frail (P = 0.03) | |||
| Institutional discharge | 14 of 71 fit vs 25 of 60 frail (P < 0.0001) | |||
| Afilalo et al. (2012), Circ Cardiovasc Qual Outcomes, USA/Canada [5] Multicentre prospective cohort study (poor quality) |
152 patients aged 70 or older undergoing elective CABG and/or valve replacement/repair Mean age 75.9 ± 4.4 years M:F–100:52 Frailty scales (1) CHS scale: gait speed, handgrip, inactivity, exhaustion, weight loss; (2) CHS scale with cognitive impairment and depression; (3) gait speed, handgrip, inactivity, cognitive impairment; (4) gait speed alone Disability scales: (1) Katz ADL scale, (2) IADL, (3) Nagi scale: pushing heavy object, benching, arm raising, picking up small objects, lifting >5 kg, walking up stairs, walking 1 mile |
Composite 30-day mortality or major morbidity | Gait speed (frailty) + Nagi score (disability) score + Parsonnet (cardiac) vs Parsonnet alone AUC = 0.76 vs 0.72 (IDI 2%; 95% CI 0–5%) |
Frailty and disability parameters when combined with cardiac risk scores increase the predictive power of major morbidity or mortality |
| Lee et al. (2010), Circulation, Canada [6] Single-centre retrospective cohort study (clinical database linked to provincial administrative database) (good quality) |
3826 patients undergoing elective cardiac surgery (n = 157 frail) Median age in non-frail 66 (IQR 57–74) vs 71 (IQR 61–78) years M:F—2828:998 Frailty defined as any impairment in ADL, ambulation or diagnosis of dementia |
In-hospital mortality | 164 of 3826 fit vs 23 of 157 frail (P < 0.0001) OR 1.8 [95% CI 1.1–3] (P = 0.03) |
Patients with either impairments of ADL, ambulation or dementia have higher mortality and need for institutional discharge This study did not compare frailty with conventional cardiac risk scores, and included patients younger than 65 years old |
| Mid-term mortality (1.8 years median follow-up) | 330 of 3826 fit vs 41 of 157 frail (P < 0.0001) HR 1.5 [95% CI 1.1–2.2] (P = 0.01) |
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| Institutional discharge | 1316 of 3826 fit vs 65 of 157 frail (P < 0.0001) OR 6.3 [95% CI 4.2–9.4] (P = 0.0001) |
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| Sundermann et al. (2011), Eur J Cardiothorac Surg, Germany [7] Single-centre prospective cohort study (poor quality) |
400 patients undergoing elective cardiac surgery aged 74 years or older Mean age 80.1 ± 4.0 years M:F–194:206 CAF score: 1–10 not frail, 11–25 moderately frail, 26–35 severe frail. Gait speed, weakness, handgrip, exhaustion, low activity, IADL, tandem balance testing, chair rise ×3, pick up object, serum albumin, creatinine, BNP, FEV1, clinical frailty scale (scored by two doctors) |
30-day mortality | 7 of 199 fit vs 13 of 170 moderately frail vs 7 of 31 severely frail AUC EuroSCORE: 0.79, STS: 0.76 and CAF score: 0.71 |
The CAF frailty score correlated with cardiac risk scores EuroSCORE (P = 035) and to the STS score (P = 0.42), suggesting that frailty overlaps with traditional cardiac risk scores The CAF is very complex, may be impractical for clinical use and has not been shown to be superior to cardiac risk scores |
| Sundermann et al. (2011), Interact CardioVasc Thorac Surg Germany [8] Single-centre prospective cohort study (good quality) |
213 patients undergoing elective cardiac surgery aged 74 years or older Mean age 80.1 ± 4.0 years M:F–110:103 Frailty score: derivative of CAF, FORECAST score: chair rise ×3, subjective reported weakness, stair climb, clinical frailty scale (scored by two doctors), serum creatinine |
1-year mortality | 7 of 99 fit vs 12 of 95 moderately frail vs 42 of 19 severely frail (P < 0.01) AUC EuroSCORE: 0.67 [95% CI 0.56–0.78], STS score: 0.67 [95% CI 0.52–0.82], FORECAST: 0.76 [95% CI 0.67–0.85] |
This was a follow-up report of 1-year outcomes of the first 213 patients enrolled in the Sundermann et al. (2011) study to reach 1-year maturity FORECAST has not yet been validated in other populations |
| ITU length of stay | 12 h ‘fit’ vs 19 h ‘moderately frail’ vs 27 h ‘severely frail’. Not significant | |||
| de Arenaza et al. (2010), Heart, Global [9] Multicentre study–secondary analysis of a RCT (good quality) |
208 patients with severe AS who underwent 6MWT prior to AVR Mean age 70.0 ± 9.2 years M:F–127:81 Frail = walk <300 m in 6 min, Fit = walk >300 m in 6 min |
Death MI or stroke at 1 year | 4.7% (n = 3) of people who walked >300 m in 6 min had adverse event vs 23.8% (n = 15) of people who walked <300 m in 6 min (P = 0.03) | In patients identified by EuroSCORE to be high risk, i.e. Score >6 (n = 63), 6MWT was able to further stratify patients into low- and high-risk groups with increased discriminatory power |
| Stortecky et al. (2011), J Am Coll Cardiol Interv, Switzerland [10] Single-centre prospective cohort study (fair quality) |
100 patients undergoing TAVI aged 70 years or older Mean age 83.7 ± 4.6 years M:F–40:60 Frailty index based on: MMSE, MNA, TUG, BADL, IADL preclinical mobility disability. 0–7 points. Dichotomized at ≥3 points = frail |
30-day mortality | OR 8.33 [95% CI 0.99–70.98] P = 0.03 |
This study demonstrates that a frailty score as part of a multidimensional geriatric assessment correlates with adverse outcomes, but is relatively time-consuming. To complete the assessments |
| 1-year mortality | OR 3.68 [95% CI 1.21–11.19] P = 0.02 |
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| 30-day MAACE | OR 4.78 [95% CI 0.96–23.77] P = 0.05 |
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| 1-year MACCE | OR 4.89 [95% CI 1.64–14.60] P = 0.003 | |||
| Green et al. (2012), JACC, USA [11] Single-centre prospective cohort study (good quality) |
159 patients aged 60 or over with severe aortic stenosis who underwent TAVI Mean age 86.2 ± 7.7 years M:F–79:80 Dichotomized into fit and frail groups by median frailty score (low albumin, slow gait speed, weak handgrip strength, IADLs and ADL) |
30-day mortality |
4 of 83 fit vs 4 of 83 frail (P = 0.9) | A risk model incorporating frailty did not significantly improve the predictive power of 1-year mortality over a clinical model using receiver operating characteristic curves |
| 30-day complications |
No significant difference between fit and frail groups | |||
| Length of stay | 6 ± 5 days fit vs 9 ± 6 days frail (P = 0.04) |
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| 1-year all-cause mortality | 7 of 83 fit vs 17 of 76 frail (P = 0.01) Frailty, adjusted for confounders, was associated with 1-year mortality: Hazard ratio 3.51 [95% CI 1.4–8.5] P = 0.007 AUC 0.727 (95% CI 0.62–0.83) clinical model vs AUC 0.772 (95% CI 0.68–0.86) frailty and clinical model |
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| Scheoenenberger et al. (2012), Eur Heart J, Switzerland [12] Single-centre prospective cohort study (fair quality) |
119 patients undergoing TAVI aged 70 years or older (including patients in the study by Stortecky et al. [10]) Mean age 83.4 ± 4.6 years M:F–53:66 Frailty index as described in [10] Functional decline was observed in 22 of 106 patients (21%) who survived 6 months following TAVR |
Functional decline at 6 months | Dichotomized frailty index (frail vs non-frail) OR 3.31 [95% CI 1.12–9.03] P = 0.02 Bivariate analysis controlled for EuroSCORE frailty index linear OR 1.56 [95% CI 1.20–2.04] P = 0.001 |
EuroSCORE and STS did not predict functional decline. However, frailty index strongly predicted functional decline Overall predictive performance was best for frailty index (Nagelkerke's R2 = 0.135) and low for EuroSCORE (Nagelkerke's R2 = 0.015) and STS score (Nagelkerke's R2 = 0.034) |
| Functional decline or death at 6 months | Dichotomized frailty index (frail vs non-frail) OR 4.46 [95% CI 1.85–10.75] P = 0.0001 Bivariate analysis controlled for EuroSCORE frailty index linear OR 1.73 [95% CI 1.36–2.20] P<0.001 |
6MWT: 6-min walk test; ADL: activities of daily living; AVR: aortic valve replacement; AUC: area under the curve; BADL: basic activities of daily living; BNP: brain natriuretic peptide; CABG: coronary artery bypass graft; CAF: comprehensive assessment of frailty score; CHS: cardiovascular health study; EuroSCORE: European System for Cardiac Operative Risk Evaluation; FEV1: forced expiratory volume in 1 s; FORECAST: Frailty predicts death One yeaR after Elective Cardiac Surgery Test; HR: hazard ratio; IDI: integrated discrimination improvement; IADL: instrumental activities of daily living; IQR: interquartile range; ITU: intensive therapy unit; MMSE: mini-mental state examination; MNA: mini-nutritional assessment; OR: odds ratio; STS-PROM: Society of Thoracic Surgeons Predicted Risk of Mortality or Major Morbidity score; TAVI: transcatheter aortic valve implantation; TUG: timed up and go; USPSTFQR: US Preventive Services Task Force Quality Rating.