Abstract
Physical frailty is an important prognostic indicator in heart failure (HF); however, few studies have examined the relationship between physical frailty and invasive hemodynamics among adults with HF. The purpose of this study was to characterize physical frailty in HF in relation to invasive hemodynamics. We enrolled 49 patients with New York Heart Association (NYHA) Class II-IV HF when participants were scheduled for a right heart catheterization (RHC) procedure. Physical frailty was measured according to the Frailty Phenotype: shrinking, weakness, slowness, physical exhaustion, and low physical activity. Markers of invasive hemodynamics were derived from a formal review of RHC tracings, and projected survival was calculated using the Seattle HF Model (SHFM). The mean age of the sample (n = 49) was 57.4±9.7 years, 67% were male, 92% had NYHA Class III/IV HF, and 67% had non-ischemic HF. Physical frailty was identified in 24 participants (49%) and was associated with worse SHFM one-year projected survival (p = 0.007). After adjusting for projected survival, physically frail participants had lower cardiac index (by both thermodilution and the Fick equation) and higher heart rates compared with those not physically frail (all p < 0.05). In conclusion, physical frailty is highly prevalent in patients with HF and is associated with low-output HF.
Keywords: Heart Failure, Hemodynamics, Physical Frailty
Heart failure (HF) is an increasingly common condition with approximately 915,000 new cases diagnosed every year.1 The rising numbers of adults with HF coupled with the complexity of clinical management2 highlights the need to pursue new lines of inquiry in HF. Frailty is a highly prevalent condition generally among older adults3 and specifically among those with cardiovascular disease.4,5 A number of studies have demonstrated high prevalence rates of frailty in HF and worse associated clinical outcomes among frail adults with HF.6-10 Following recommendations by several HF groups to include a frailty assessment in HF,11,12 there is a critical need to study all aspects of physical frailty13 in HF, including the relationship between physical frailty and other commonly used markers in HF such as invasive hemodynamics. The purpose of this study was to characterize physical frailty in HF by quantifying differences in invasive hemodynamics between physically frail and non-physically frail patients with HF.
Methods
This article addresses a primary aim of a U.S. National Institutes of Health-funded cross-sectional study that involved comprehensive measurements of physical frailty and invasive hemodynamics in HF. The study was conducted between July 2015 and March 2016. After initial screening and approval by the HF cardiologists, potential participants who met the inclusion criteria were approached when scheduled for a clinically-indicated right heart catheterization (RHC) procedure (Figure 1). Physical frailty criteria were assessed usually on the same day as, or within 7 days of, the RHC procedure.
Figure 1. Enrollment Flow Diagram for Symptom Biology and Accelerated Aging in Heart Failure Study.
We screened 64 adults for our study, 50 adults were enrolled, and 49 adults were analyzed.
The sampling frame for this study was adult women and men with HF who receive care from a HF practice (outpatient clinic and/or inpatient facilities) at an academic medical center in the Pacific Northwest and required a RHC procedure during the study period. Formal inclusion criteria included age ≥ 21 years, ability to read and comprehend 5th grade English, New York Heart Association (NYHA) functional class II-IV (i.e. current HF symptoms), and undergoing RHC for clinical purposes. Participants were excluded if they had previously had a heart transplant or ventricular assist device, had major and uncorrected hearing dysfunction, or were otherwise unable to complete the requirements of the study (e.g. life-threatening illness). This study was approved by the university Institutional Review Board, and written informed consent was obtained from all participants.
Data on age, gender, and race were obtained using a socio-demographic questionnaire. Functional status (i.e. NYHA) was assessed and documented by an attending HF cardiologist. Data on history, duration, etiology, and treatment of HF along with clinical characteristics were collected through an in-depth review of the electronic medical record. Comorbid conditions were summarized using the Charlson Comorbidity Index.14
All RHC procedures were performed without the use of sedation by either advanced HF cardiologists or interventional cardiologists. Following completion of the RHC procedure, we reviewed the RHC tracings and reports. We collected data and calculated pressures based on waveforms, including right atrial pressure, pulmonary artery pressures, pulmonary capillary wedge pressure, and arterial blood pressure, along with the reported heart rate. We collected data on flow based on cardiac output and cardiac index, both as measured by thermodilution and as calculated by the Fick equation (using assumed VO2). We also calculated the pulmonary artery pulsatility index (pulmonary artery systolic pressure – pulmonary artery diastolic pressure)/right atrial pressure, and the right ventricular systolic work index (pulmonary artery mean pressure – right atrial pressure)*(cardiac index/heart rate).15 Finally, we collected data on oxygen extraction, as measured by mixed venous oxygen saturation.
We collected data from the most recent transthoracic echocardiogram, including left ventricular end-diastolic diameter and visually estimated left ventricular ejection fraction. We also collected data from recent cardiopulmonary exercise testing, including peak oxygen consumption (peak VO2,), respiratory quotient, ventilatory equivalent of carbon dioxide slope coefficient, and oxygen consumption at anaerobic threshold. The Seattle HF Model (SHFM) 1-year projected survival was calculated based on the model developed by Levy and colleagues (2006)16 and available online (https://depts.washington.edu/shfm/); this model uses objective clinical variables and HF treatments to generate estimated projected survival.
We assessed cognitive function in-person using the Montreal Cognitive Assessment (MoCA).17 The MoCA is a cognitive screening tool, designed for first-line clinicians with an adjusted algorithm for persons with chronic cardiovascular disease (score < 24/30) that is 100% sensitive to detect amnestic mild cognitive dysfunction in this population.18 A MoCA score of 24 was used as the cut point for mild cognitive dysfunction in this study.
Based on the Frailty Phenotype,3 a well-validated measure in older adults, we measured 5 physical frailty criteria: shrinking, weakness, physical exhaustion, slowness and low physical activity (Figure 2). We measured shrinking by a self-report of unintentional weight loss of > 10 pounds over the last year. We measured weakness of the upper extremities using a hand-held Smedley III Digital Grip Strength Tester (Takei Scientific Instruments, Japan). Participants were asked to perform standing maximal isometric contraction with their dominant hand 3 consecutive times with a 5-second rest period between each contraction. Weakness was determined using gender and body mass index cut points based on the Frailty Phenotype.3 We also measured weakness of the lower extremities using 5-repeat chair stands. Participants were assessed and timed on their ability to rise out of a chair 5 times without using their arms; a cut point of > 12 seconds or inability to rise 5 times indicated weakness.19 We measured slowness by clocking the time (in seconds) it took a participant to walk 4 meters. Participants were asked to walk at their usual speed, starting at 1 meter before the start line and walking to 1 meter past the finish line. They were permitted to use walking aides (e.g. canes or walkers). Based on a review of cut points for slow gait speed,20,21 we used a cut point of < 0.9 meters per second to indicate slowness. We measured physical exhaustion using the 13-item Functional Assessment of Chronic Illness Therapy Fatigue Scale (FACIT-F; v.4).22 The FACIT-F captures self-reported tiredness, weakness, and inability to perform activities of daily living as a result of fatigue. The 13 items are rated from 0 (not at all) to 4 (very much); cumulative scores range from 0 to 52 with lower scores indicating more fatigue. Cronbach's α of the FACIT-F in this sample was 0.92. Based on the application of the FACIT-F in the general population,23 we used a cut point of < 17 to identify those with severe physical exhaustion. We measured level of physical activity with the question “During the past week, how much total time did you spend exercising?” Those who reported less than 1 hour per week (to approximate expending ∼300 kcal/week in physical activity) were classified as having low physical activity. We compared responses to this question with the 12-item Duke Activity Status Index (DASI), an instrument of functional capacity that assesses activities related to major aspects of physical function24 and has demonstrated good reliability and validity in HF.25 Cronbach's α of the DASI in this sample was 0.83.
Figure 2. Measures to Assess Physical Frailty in Heart Failure Based on the Frailty Phenotype Criteria.
Based on the Frailty Phenotype, we assessed and scored each of the 5 criteria: shrinking, weakness, slowness, physical exhaustion, and low physical activity. Each criteria was reviewed and adapted for nuances specific to the heart failure population.
After completing the measures for each of the 5 criteria, the scores were totaled (range 0 to 5; Figure 2). Each participant was then classified as either “non-frail” (0/5 criteria met), “pre-frail” (1-2 criteria met), or “physically frail” (≥3 criteria met). Because of the small numbers in the non-frail group (n = 1), we combined this group with the pre-frail group (n = 24) (i.e. “not physically frail”), as compared with the “physically frail” group.
Characteristics of the sample are presented using standard descriptive statistics, including measures of central tendency and dispersion. Comparative statistics (Student's t-, Mann-Whitney U, Fisher exact tests, or the Pearson χ2) were used to determine significant differences in demographic and clinical characteristics, invasive hemodynamics, and individual physical frailty criteria measures between the 2 groups. Reported effect sizes for individual physical frailty criteria were calculated using, or converted to, Cohen's d. Multivariate linear regression was used to compare invasive hemodynamics between groups, adjusting for SHFM 1-year projected survival. Significance was set at α < 0.05. All analyses were performed using Stata/MP version 13MP (StataCorp, College Station, TX).
Results
Characteristics of the sample are presented in Table 1. The age of the sample ranged from 27 to 75 years. We identified physical frailty in 24 (49%) participants and pre-frailty in 24 (49%) participants; 1 participant was non-frail. Ten (20%) participants met 1/5 criteria, 14 (29%) met 2/5 criteria, 11 (22%) met 3/5 criteria, 9 (18%) met 4/5 criteria, and 4 (8%) met 5/5 criteria. Seven participants were unable to complete 5 chair stands, and 2 participants were unable to complete the gait speed assessment due to profound weakness. Unintentional weight loss and weakness by grip strength were not significantly different between the groups (Table 2). Gait speed was the most significant discriminatory criteria.
Table 1. Characteristics of the sample and by level of physical frailty*.
| Total (n = 49) | Not Physically Frail (n = 25)† | Physically Frail (n = 24) | p value‡ | |
|---|---|---|---|---|
|
|
||||
| Age (years) | 57.4±9.7 | 54.8±11.7 | 60.1±6.4 | 0.06 |
| Male | 33 (67%) | 19 (76%) | 14 (58%) | 0.19 |
| Non-Hispanic Caucasian | 40 (82%) | 22 (88%) | 18 (75%) | 0.29 |
| Body mass index (kg/m2) | 30.3±7.6 | 31.0±8.4 | 29.5±6.9 | 0.52 |
| Charlson Comorbidity Index (weighted) | 2.3±1.2 | 2.2±1.2 | 2.4±1.2 | 0.53 |
| Atrial fibrillation | 26 (53%) | 15 (60%) | 11 (46%) | 0.32 |
| Stage 3 chronic kidney disease | 9 (18%) | 3 (12%) | 6 (25%) | 0.29 |
| Out-patient (versus in-patient) at enrollment | 34 (69%) | 20 (80%) | 14 (58%) | 0.13 |
| Time with Heart failure (years) | 8.4 [2.4-14.8] | 8.4 [4.8-15.0] | 8.0 [1.0-13.5] | 0.21 |
| New York Heart Association Functional Class | <0.01 | |||
| Class II | 4 (8%) | 4 (16%) | 0 (0%) | |
| Class III | 34 (69%) | 19 (76%) | 15 (63%) | |
| Class IV | 11 (23%) | 2 (8%) | 9 (38%) | |
| Non-ischemic etiology | 33 (67%) | 19 (76%) | 14 (58%) | 0.19 |
| Prescribed a β-blocker | 35 (71%) | 20 (80%) | 15 (63%) | 0.22 |
| Prescribed an angiotensin-converting enzyme-inhibitor or angiotensin II receptor blocker | 39 (80%) | 21 (84%) | 18 (75%) | 0.50 |
| Prescribed an aldosterone antagonist | 25 (51%) | 14 (56%) | 11 (46%) | 0.48 |
| Prescribed digoxin | 11 (23%) | 8 (32%) | 3 (13%) | 0.17 |
| Prescribed a vasodilator (nitrate or hydralazine) | 10 (20%) | 5 (20%) | 5 (21%) | 1.00 |
| ICD or Biventricular ICD | 39 (80%) | 23 (92%) | 16 (67%) | <0.04 |
| Serum sodium (mEq/L) | 136.8±3.9 | 138.1±2.8 | 135.4±4.4 | <0.02 |
| Serum hemoglobin (g/dL) | 13.3±1.7 | 13.4±1.7 | 13.2±1.6 | 0.67 |
| Serum creatinine (mg/dL) | 1.2±0.5 | 1.1±0.3 | 1.3±0.6 | 0.46 |
| Serum B-type natriuretic peptide (pg/mL) | 478 [267-1103] | 349 [111-807] | 699 [347-1323] | 0.08 |
| Serum N-terminal pro-B-type natriuretic peptide (pg/mL) | 1234 [622-2686] | 714 [519-1158] | 1774 [985-2958] | 0.17 |
| Left ventricular end-diastolic diameter (cm) | 6.6±1.0 | 6.7±1.0 | 6.4±1.0 | 0.34 |
| Left ventricular ejection fraction (%) | 24.3±8.9 | 25.2±6.8 | 23.3±10.7 | 0.47 |
| Peak VO2 (mL/kg/min) | 15.4±3.6 | 16.2±3.7 | 13.6±2.8 | <0.05 |
| VO2 at aerobic threshold (mL/kg/min) | 12.0±3.5 | 12.8±3.6 | 10.2±2.6 | 0.07 |
| Respiratory quotient | 1.1±0.2 | 1.1±0.2 | 1.2±0.1 | 0.55 |
| VE/VCO2 slope coefficient | 32.8±5.3 | 32.0±4.9 | 34.5±6.1 | 0.33 |
| Seattle Heart Failure Model projected 1 year survival (%) | 93.0 [81.0-96.0] | 95.0 [92.0-97.0] | 89.0 [70.0-95.0] | <0.01 |
| Mild cognitive dysfunction | 16 (33%) | 2 (8%) | 14 (58%) | <0.001 |
| Right atrial pressure (mmHg) | 8.3±4.2 | 8.0±4.0 | 8.5±4.5 | 0.68 |
| Pulmonary artery systolic pressure (mmHg) | 41.3±15.1 | 38.2±14.0 | 44.6±15.7 | 0.14 |
| Pulmonary artery diastolic pressure (mmHg) | 19.1±7.8 | 16.8±7.2 | 21.4±7.9 | <0.04 |
| Pulmonary capillary wedge pressure (mmHg) | 18.8±8.1 | 17.2±7.1 | 20.4±9.0 | 0.18 |
| Mixed venous oxygen saturation (%) | 61.8±7.3 | 64.2±6.6 | 59.2±7.1 | <0.02 |
| Cardiac output (L/min by thermodilution) | 4.7±1.5 | 5.3±1.6 | 4.2±1.1 | <0.01 |
| Cardiac index (L/min/m2 by thermodilution) | 2.3±0.6 | 2.5±0.6 | 2.1±0.5 | <0.03 |
| Cardiac output (L/min by Fick equation) | 4.0±1.1 | 4.3±1.1 | 3.7±1.0 | 0.05 |
| Cardiac index (L/min/m2 by Fick equation) | 2.0±0.5 | 2.1±0.4 | 1.9±0.5 | 0.18 |
| Arterial systolic blood pressure (mmHg) | 110.7±18.2 | 115.4± 15.8 | 105.8±19.6 | 0.08 |
| Arterial diastolic blood pressure (mmHg) | 69.7±8.6 | 69.1±7.4 | 70.4±9.9 | 0.64 |
| Heart rate (beats per min) | 79.0±16.2 | 73.4±12.7 | 84.8±17.6 | <0.02 |
| Pulmonary artery pulsatility index | 2.7 [2.1-3.4] | 2.8 [2.0-3.4] | 2.7 [2.1-3.6] | 0.99 |
| Right ventricular stroke work index | 0.57±0.28 | 0.59±0.27 | 0.55±0.28 | 0.59 |
Continuous data are presented as mean ± SD or median [interquartile range]; categorical data as number of patients (percentage of sample)
Not physically frail includes both non-frail (n = 1) and pre-frail (n = 24)
p values comparing physically frail versus not physically frail
Abbreviations: ICD, implantable cardioverter defibrillator; VE/VCO2, ventilatory equivalent of carbon dioxide slope coefficient; VO2, peak oxygen consumption.
Table 2. Physical frailty characteristics of the sample and by level of physical frailty*.
| Total (n = 49) | Not Physically Frail (n = 25)† | Physically Frail (n = 24) | p value‡ | Cohen's d Effect Size [95%CI] | |
|---|---|---|---|---|---|
|
|
|||||
| Physical Frailty Measures: | |||||
| Unintentional weight loss | 17 (35%) | 6 (24%) | 11 (46%) | 0.11 | 0.54 [-0.13, 1.22] |
| Weakness by handgrip strength (kg) | |||||
| Women | 24.1±9.3 | 30.6±10.5 | 20.1±6.0 | 0.06 | 1.32 [0.18, 2.42] |
| Men | 41.1±7.8 | 42.0±8.6 | 39.8±6.8 | 0.43 | 0.27 [-0.42, 0.96] |
| Weakness by chair stands (s)§ | 17.6±8.0 | 14.4±7.1 | 21.3±7.6 | <0.005 | 0.95 [0.31, 1.57] |
| Slowness (m/s)§ | 0.9±0.2 | 1.1±0.2 | 0.7±0.2 | <0.001 | 2.15 [1.42, 2.87] |
| Physical exhaustion (FACIT-F; 0-52) | 24.0±10.6 | 28.4±9.6 | 19.5±9.8 | <0.005 | 0.92 [0.33, 1.51] |
| Low physical activity | 33 (67%) | 12 (48.0) | 21 (88%) | <0.01 | 1.12 [0.25, 2.13] |
| Duke Activity Status Index (METS; 0-58.2) | 5.9±1.6 | 6.8±1.4 | 5.1±1.3 | <0.001 | 1.23 [0.62, 1.84] |
Continuous data are presented as mean ± SD or median [interquartile range]; categorical data as number of patients (percentage of sample)
Not physically frail includes both non-frail (n = 1) and pre-frail (n = 24)
p values comparing physical frailty versus not physically frail
data only includes those who could successfully complete these assessments (i.e. several could not complete 5-repeat chair stands or gait speed)
Abbreviations: CI, confidence interval; FACIT-F, Functional Assessment of Chronic Illness Therapy Fatigue Scale; METS, metabolic equivalents.
Compared with those who were not physically frail, physically frail participants had significantly higher proportions of NYHA Class IV functional classification, lower serum sodium levels, and lower peak VO2 (Table 1). Physically frail participants also had significantly higher proportions of mild cognitive dysfunction and worse 1-year projected survival than those who were not physically frail. There were no significant differences between many other demographic and clinical characteristics.
Multiple measures of invasive hemodynamics were significantly different comparing physically frail participants versus those not who were not physically frail (Table 1). Physically frail participants had significantly higher pulmonary artery diastolic pressures, lower mixed venous oxygen saturations, lower cardiac outputs and cardiac indexes (by thermodilution), and higher heart rates than those who were not physically frail in unadjusted models (Table 3). After adjusting for SHFM 1-year projected survival, cardiac output (by both thermodilution and Fick equation) and heart rate remained significantly different (Table 3).
Table 3. Unadjusted and adjusted differences in invasive hemodynamic characteristics between levels of physical frailty.
| Unadjusted* | Adjusted*† | |||
|---|---|---|---|---|
|
| ||||
| β±SE | p value | β±SE | p value | |
|
|
||||
| Right atrial pressure (mmHg) | 0.5±1.2 | 0.68 | -0.8±1.2 | 0.49 |
| Pulmonary artery systolic pressure (mmHg) | 6.5±4.2 | 0.13 | 3.7±4.5 | 0.42 |
| Pulmonary artery diastolic pressure (mmHg) | 4.6±2.2 | <0.04 | 3.2±2.3 | 0.17 |
| Pulmonary capillary wedge pressure (mmHg) | 3.1±2.3 | 0.18 | 0.8±2.4 | 0.74 |
| Mixed venous oxygen saturation (%) | -5.0±2.0 | <0.02 | -3.0±2.0 | 0.14 |
| Cardiac output (L/min by thermodilution) | -1.1±0.4 | <0.01 | -0.9±0.4 | <0.05 |
| Cardiac index (L/min/m2 by thermodilution) | -0.4±0.2 | <0.03 | -0.2±0.2 | 0.16 |
| Cardiac output (L/min by Fick equation) | -0.6±0.3 | 0.05 | -0.8±0.3 | <0.03 |
| Cardiac index (L/min/m2 by Fick equation) | -0.2±0.1 | 0.18 | -0.3±0.1 | 0.09 |
| Heart rate (beats per minute) | 11.3±4.4 | <0.02 | 9.8±4.6 | <0.05 |
| Pulmonary artery pulsatility index | -0.1±0.6 | 0.87 | 0.2±0.7 | 0.78 |
| Right ventricular stroke work index | -0.04±0.08 | 0.59 | -0.02±0.09 | 0.81 |
Slope coefficient for physically frail participants (versus not physically frail)
Adjusting for Seattle Heart Failure Model 1-year survival score (a composite of clinical variables and heart failure treatments)
Abbreviations: SE, standard error
Discussion
The results from this study have generated several novel findings. First, using clinically applicable measures, we have shown that physical frailty is highly prevalent among patients with HF. Second, the characterization of physical frailty in HF in this sample demonstrates that physical frailty is associated with more advanced stages of HF. Finally, we are the first study to comprehensively show multiple invasive hemodynamic measures are significantly worse in physically frail patients with HF compared with those who are not physically frail.
In comparing our findings with other HF studies using the Frailty Phenotype, we observed slightly higher prevalence rates of physical frailty and pre-frailty, although differences in sample characteristics must be considered.7-10,26 Our rates of physical frailty could be higher compared with other HF settings because our academic medical center is a referral site for advanced HF, and all participants required a clinically-indicated RHC procedure (e.g. to stage for advanced therapies). Further, we enrolled from both hospital and clinic settings in order to capture a wide cross-section of patients with moderate to advanced HF.
The findings of this study illustrate physically frail patients with HF have worse functional status, serum sodium levels, cognitive function, and projected survival. It is not surprising that all physically frail patients were either Class III or IV functional class. The inability to rise from a chair and walk down the hall, much less complete any form of physical activity, is characteristic of impaired function in HF. Together with other studies in HF,6,7 we also show evidence that cognitive function is significantly worse among physically frail patients with HF. Finally, the significant difference in 1-year projected survival is in line with other studies that have demonstrated worse clinical outcomes in frail patients with HF.6,7
This was the first study to comprehensively examine the relationship between physical frailty and invasive hemodynamics among patients with HF. After adjusting for SHFM 1-year projected survival, we found physically frail patients with HF had significantly lower cardiac outputs and higher heart rates than those who were not physically frail. Differences in echocardiographic structural and functional parameters between frail and non-frail older adult patients have recently been noted;27 as such, studying differences in other invasive and non-invasive functional markers would help us better understand the biology of physical frailty in HF. In our study, the low mixed venous oxygen saturation and low flow at rest coupled with low peak VO2 and elevated VE/CO2 during exercise provides evidence that physical frailty is, in part, a manifestation of low-output HF. It also aligns with the cycle of physical frailty, which is conceptualized as decreased physiological reserves resulting from the cumulative decline across physiologic systems.3,28 Physical frailty is evidence that the body is slowing down; in HF, the body is slowing down because HF is an inability of the heart to adequately perfuse and deliver oxygen to the tissues. Thus, the findings from this study provide preliminary evidence of some of the similarities between the pathophysiology of HF and the presentation of physical frailty. In future research, as described by Flint and colleagues (2012),29 studying physical frailty in patients receiving mechanical circulatory support or other advanced therapies presents a unique opportunity to dissect the similarities and differences between physical frailty and HF.
The design of this study demonstrates the feasibility of assessing physical frailty in HF based on the Frailty Phenotype.3 Physical frailty was easily assessed in about 5-7 minutes in both outpatient and inpatient settings. Notably, we assessed weakness in both the upper and lower extremities, and we found the lower extremity assessment was more useful. This is the first study to incorporate 5-repeat chair stands as part of an assessment of physical frailty in HF. In the future, we would recommend using 5-repeat chair stands as they were more informative than grip strength, better captured a function most patients with HF encounter every day (e.g. rising from a chair or toilet), and have been shown to predict falls.19
A number of clinical implications can be drawn from these results. First, our assessment of physical frailty was feasible and can easily be adapted for both outpatient and inpatient clinical settings. The 5 criteria together are informative in a comprehensive and additive manner, and we would recommend using all 5 criteria when assessing physical frailty. Second, the presence of physical frailty in a patient with HF could be a useful clinical indicator of low-output HF without having to perform a RHC procedure. Finally, based on the collective significant differences between the groups, we have demonstrated physical frailty is revealing more advanced stages of HF functionally-, cognitively-, and hemodynamically-speaking. An assessment of physical frailty provides the incremental benefit of identifying those advanced HF patients at higher risk for poor clinical- and patient-oriented outcomes. Moreover, given the association with low-output HF, a physical frailty assessment provides a tool by which to gauge changes following advanced therapies such as mechanical circulatory support.
This study has a few limitations. First, beyond the limitations inherent in cross-sectional studies, we had a limited sample size, and thus, we may have been underpowered to detect some differences. Second, our sample was comprised of mostly young, Non-Hispanic Caucasian patients with moderate to advanced HF. All of the participants required a RHC procedure for clinical purposes, indicating that they were relatively sick, and referral bias for advanced HF management must be taken into consideration. Hence, our findings in a sample of relatively young, sick, mostly advanced HF patients are not generalizable to all patients with HF. Finally, only one participant was non-frail, and thus, we were limited to a comparison of physical frailty with pre-frailty; however, the significant differences between these two groups would likely translate to larger differences between physically frail and non-frail patients with HF.
Acknowledgments
Funding: Pre-doctoral funding for Quin Denfeld provided by the National Institutes of Health/National Institute of Nursing Research (NIH/NINR) Ruth L. Kirschstein National Research Service Award (F31NR015936; Denfeld) and the National Hartford Centers of Gerontological Nursing Excellence (NHCGNE) Patricia G. Archbold Scholar Program (Denfeld). Post-doctoral funding for Quin Denfeld provided by NIH/National Institute of Heart, Lung, and Blood (NIH/NHLBI) at Oregon Health & Science University Knight Cardiovascular Institute (T32HL094294; Thornburg). The content is solely the responsibility of the authors and does not necessarily represent the official views of the NIH/NINR, NIH/NHLBI, or the NHCGNE.
Footnotes
Conflicts of Interest: None
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