Frailty and outcomes in heart failure patients from high-, middle- and low-Income countries.

Abstract

There is little information on the incremental prognostic importance of frailty beyond conventional prognostic variables in heart failure (HF) populations from different country income levels. 3429 adults with HF (age 61±14 years, 33% women) from 27 high-, middle- and low-income countries were prospectively studied. Baseline frailty was evaluated by the Fried index, incorporating handgrip strength, gait speed, physical activity, unintended weight loss and self-reported exhaustion. Mean left ventricular ejection fraction was 39±14% and 26% had New York Heart Association (NYHA) class III/IV symptoms. Participants were followed for a median (25th-75th percentile) 3.1 (2.0-4.3) years. Cox proportional hazards models for death and HF hospitalization adjusted for country income level; age; sex; education; HF etiology; left ventricular ejection fraction; diabetes; tobacco and alcohol use; NYHA functional class; HF medication use; blood pressure; hemoglobin, sodium and creatinine concentrations were performed. The incremental discriminatory value of frailty over and above the MAGGIC risk score was evaluated by the area under the receiver-operating characteristic curve. At baseline, 18% of participants were robust, 61% pre-frail and 21% frail. During follow-up, 565 (16%) participants died and 471 (14%) were hospitalized for HF. Respective adjusted hazard ratios [HRs (95% CI)] for death among the prefrail and frail were 1.59 (1.12-2.26) and 2.92 (1.99-4.27). Respective adjusted HRs (95% CI) for HF hospitalization were 1.32 (0.93-1.87) and 1.97 (1.33-2.91). Findings were consistent among different country income levels and by most subgroups. Adding frailty to the MAGGIC risk score improved the discrimination of future death and HF hospitalization. Frailty confers substantial incremental prognostic information to prognostic variables for predicting death and HF hospitalization. The relationship between frailty and these outcomes is consistent across countries at all income levels.