Heart failure

Frailty doubles risk of death in HF patients

Frailty in patients hospitalised for heart failure is linked with double the risk of death at 12-months post-admission, an Australian cohort study has revealed.

Cardiologists say a focus on interventions that improve, or even reverse, frailty scores following a first acute HF hospitalisation are needed in this particularly vulnerable group of patients.

The NSW Heart Failure Snapshot study – one of the largest prospective studies of acute heart failure in Australia – recruited 811 patients admitted to 24 hospitals across NSW and the ACT.

Professor Peter Macdonald from the Victor Chang Cardiac Research Institute and a study investigator told the limbic the NSWHF Snapshot was an elderly cohort with high comorbidity – the mean age of patients was 77 years and 71% of patients were frail at baseline – and one that reflects the challenges of the clinical reality that doctors treating HF face daily.

Within 30-days post-discharge 24% of patients had been re-admitted and 178 patients died within 12 months post-discharge.

According to Professor Macdonald, frailty was one of the biggest predictors of death at 12 months. Other independent predictors included hypokalaemia at discharge and readmission within 30 days of baseline admission.

“We conducted frailty assessments on the patients that came in, which is something you can’t get through administrative data, and those that were frail on that measure had double the mortality at 12 months post-admission,” says Professor Macdonald.

“The other striking factor is the comorbidity and while it’s not surprising that the more problems you have the worse your long term outcome, it’s the combination of the age of the patients their frailty status and their other comorbidities that are the major drivers of mortality in this cohort,” he added.

Under-utilisation of evidence-based heart failure therapies

The study also found that those who were readmitted within 30 days and those who died within 12 months had much lower rates of prescription of ACEi or ARB at discharge from the index admission.

Speaking about the under-utilisation of evidence-based heart failure therapies Professor Macdonald said while it wasn’t clear from the study what proportion of this non-prescription was due to an absolute contraindication he suspects that it is likely led by a concern from doctors that frail comorbid patients would not tolerate the drugs.

“It’s difficult to establish the evidence-based medication in these groups of patients – it’s not something you see a lot in the guidelines. Guidelines are based on the results of clinical trials and this group of patients don’t make it into these trials,” he said pointing out that the average age of many HF trials is less than 65 years.

“The average age of patients in the NSW Heart Failure Snapshot was 77 – it’s a very different type of patient that is coming into the hospital with acute decompensated heart failure – but it’s the clinical reality so we have a real gap between the clinical trial world and the real world of heart failure.”

Professor Macdonald argues that referral to a multidisciplinary heart failure program could see outcomes improved for this group of patients but he noted that only 50% of patients in the NSWHF Snapshot had been referred to one.

“I think one of the real values of these programs where you’ve got a nurse and a pharmacist involved is that they can be very effective in making sure that patients are on evidence-based treatments and that they’re receiving the maximum tolerated doses of these medications,” he noted adding that such multidisciplinary programs will work at improving frailty scores.

“There’s an increasing recognition that frailty is a major issue in HF. Obviously we see it more in the elderly but it doesn’t mean that it’s irreversible once you develop it. There is a big focus now on reversing frailty particularly if you’re considering a major intervention like cardiac surgery or TAVI.”

Meanwhile, for patients who have had HF therapy withheld during a hospital admission, Professor Macdonald emphasised the reinstatement of therapy by the time blood pressure and other factors have stabilised stressing the importance of a referral to an outpatient-based program where patients can be reviewed and up titrated.

“The more frail and more comorbid a patient is during the admission the more challenging it’s going to be but it’s do-able because one of the take-home message is that we should be trying to get as many people as we can on evidence-based treatment and if patients are unable to tolerate that, for whatever reason, then that identifies a group who clearly have a much high mortality risk.”

The NSWHF Snapshot study is published here

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