Physical frailty—slowness, exhaustion and inactivity—may be improved in patients with heart failure (HF) by treating mitral regurgitation (MR), though patients in advanced HF may have irreversible negative effects on elements of physical frailty, a new study shows.

These findings were reported by Clemens Metze, MD, of the University Hospital Cologne, Germany, and colleagues in a manuscript published Wednesday online in the JACC: Heart Failure.

Decreased physiological momentum and enhanced vulnerability to stressors characterize the concept of frailty as a clinical syndrome. Frailty is particularly common among the elderly, who also disproportionately experience cardiovascular disease. Physical frailty is seen is roughly half the patients who undergo percutaneous mitral valve repair (PMVR) and half the patients who have HF.

This study evaluated the frailty levels of 258 patients (mean age=78±9 years, 42% female, 55% had secondary MR) using the Fried criteria (weight loss, weakness, exhaustion, slowness and low activity levels) before and 6 weeks after undergoing PMVR, with and without exposure to heart failure.

Of the 258 patients, 118 (45.7%) demonstrated frailty at baseline, and 74 patients demonstrated frailty at follow-up (28.7%, p<0.001). The domains of slowness, exhaustion and inactivity decreased significantly, but there was no change in levels of weakness. Comorbidities associated with frailty at baseline were N-terminal pro-B type natriuretic peptide (NT-proBNP) levels and functional capacity. Frailty post-PMVR was not associated with any level of NT-proBNP.

There were some predictors of reversibility of post-PMVR frailty: New York Heart Association functional class <IV, absence of weakness and an overall lower frailty score. In patients who experienced new frailty (hazard ratio [HR]=1.41, 95% confidence interval [CI]=0.41-4.86), reversal of frailty (HR=1.41, 95% CI=1.03-4.57) or persistent frailty (HR=3.26, 95% CI=1.62-6.57; p=0.006 for trend), mortality increased significantly, compared with patients who consistently demonstrated non-frailty.

Overall, treating MR in patients with HF reduces physical frailty to about half before PMVR treatment, especially in patients with less advanced stages of the disease or symptoms. The investigators noted that frailty should be a primary treatment target.

In an accompanying editorial, Suzanne V. Arnold, MD, MHA, of Saint Luke’s Mid America Heart Institute, Kansas City, Missouri, described the background research of frailty and how it threatens and can worsen potential prognosis. She discussed the connection between cardiovascular disease and the development of frail-like symptoms.

“Identifying patients with frailty that is potentially reversible is imperative because these patients have the most potential to gain from treatments that target the symptoms of cardiovascular disease, even if these treatments are invasive,” she wrote.

Though reducing frailty levels in patients with reversible frailty is optimal, other patients may still benefit from treatment to reduce frailty, she noted, and there are many more questions to be answered regarding the frailty management process.

“Beyond patient selection and treatment choice, we need to continue to work to refine our procedures to reduce complications, increase early mobilization, and cautiously limit length of stay, all of which will minimize the acute insult to frail patients and allow them to recover more quickly,” the editorialist concluded.

Sources:

Metze C, Iliadis C, Körber MI, et al. Disentangling Heart Failure and Physical Frailty: Prospective Study of Patients Undergoing Percutaneous Mitral Valve Repair. JACC Heart Fail. 2023 May 24 (Article in press).

Arnold SV. Reversal of Frailty: A Patient-Centered Outcome for Interventions in Elderly Patients with Heart Failure. JACC Heart Fail. 2023 May 24 (Article in press).

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