The prevalence of frailty in heart failure: A systematic review and meta-analysis☆,☆☆
Introduction
In recent years, frailty, often defined as “a biologic syndrome of decreased reserve and resistance to stressors, resulting from cumulative declines across multiple physiologic systems, and causing vulnerability to adverse outcomes,” [18] (p. M146) has emerged as a significant area of research in heart failure (HF). Given the value of frailty in predicting worse clinical- and patient-oriented outcomes among older adults in general [18] and adults with HF in particular [6], [9], [12], [13], [19], [32], there is now a substantial, worldwide literature base on frailty in HF. Indeed, HF is associated with accelerated biological aging [49] and, as a result, geriatric syndromes like frailty [11] are more likely to present irrespective of chronological age. Additionally, recent scientific statements have recommended a formal frailty assessment as a critical element in determining the care of adults with advanced HF [16], those being listed for heart transplant [33], and those in skilled nursing facilities [28].
A number of published studies on frailty in HF and several systematic reviews have provided insight into the overlap between frailty and HF, including proposed pathogenic mechanisms and recommended interventions to prevent or ameliorate frailty [5], [11], [17], [21], [25]. The overall prevalence and knowledge of factors that influence frailty in HF, however, are reported with considerable inconsistency across studies and have not been effectively synthesized through prior narrative reviews. The purpose of this meta-analysis was to quantitatively synthesize published literature on the prevalence of frailty in HF. In an effort to extend the perspective of frailty in HF beyond a strictly geriatric syndrome, we also examined the relationship between study characteristics (i.e. age and functional class of the sample) and prevalence of frailty in HF using meta-regression.
Section snippets
Data sources and study eligibility
This study was a meta-analysis of published data-based studies on frailty in HF. Studies were considered eligible for inclusion if they met the following criteria: 1) sample or subsample consisted of HF patients, and 2) the prevalence (i.e. n or rate with denominator) of frailty in the sample or subsample of HF patients was available using any form of frailty assessment or portion of an assessment (e.g. gait speed or grip strength). Both observational and interventional studies (baseline data)
Included studies
Results of study identification, screening, eligibility, and inclusion are outlined in the PRISMA flow diagram (Fig. 1). Twenty-six published studies [1], [4], [6], [7], [8], [9], [12], [13], [14], [19], [26], [27], [29], [31], [32], [35], [37], [38], [40], [41], [42], [43], [44], [47], [48], [50], involving a total of 6896 patients with HF, were considered eligible and included in the meta-analysis (Table 1). Seventeen studies were classified as “Physical Frailty” as they used primarily
Discussion
Despite substantial variation across published studies, we derived a precise estimate of the prevalence of frailty in HF based on data from 26 published studies involving 6896 patients with HF worldwide. In this first known meta-analysis of the prevalence of frailty in HF, it is evident that frailty affects almost one in every two adults with HF. Moreover, the prevalence of frailty in HF is not a function of age or functional classification but perhaps also reflective of other mechanisms.
Conclusions
In this meta-analysis of frailty in HF, our findings demonstrate that frailty affects almost one in every two patients with HF. These results point to the importance of studying frailty in HF across a patient's lifespan and broadening our view of frailty beyond a strictly geriatric syndrome. As such, there is a need to critically examine all aspects of frailty in HF, including standardizing the measurement of frailty in HF, understanding the underlying pathological mechanisms, and mitigating
Conflicts of interest
None.
Acknowledgments
The authors would like to thank Jonathan Auld, RN, MS, CNL, MAT for assisting with data verification.
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All authors take responsibility for all aspects of the reliability and freedom from bias of the data presented and their discussed interpretation.
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Funding acknowledgements: This work was supported by the National Institutes of Health/National Institute of Nursing Research (NIH/NINR) Ruth L. Kirschstein National Research Service Award (1F31NR015936-01; Denfeld), the National Hartford Centers of Gerontological Nursing Excellence (NHCGNE) Patricia G. Archbold Scholar Program (Denfeld) and an ARCS Scholar Award (Denfeld). Current post-doctoral funding for Quin Denfeld was provided by NIH/National Heart, Lung, and Blood Institute (NIH/NHLBI) at Oregon Health & Science University Knight Cardiovascular Institute (2T32HL094294; 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.