Frailty Scale Predicts Death and Disability After Aortic Valve Replacement

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In addition to frailty, afib, oxygen-dependent lung disease, and kidney disease were identified as risk factors for poor outcomes following TAVR or SAVR.
In addition to frailty, afib, oxygen-dependent lung disease, and kidney disease were identified as risk factors for poor outcomes following TAVR or SAVR.

The Essential Frailty Toolset (EFT) successfully predicted disability and death in patients following transcatheter aortic valve replacement (TAVR) and surgical aortic valve replacement (SAVR), according to a study published in the Journal of the American College of Cardiology.

The Frailty Assessment Before Cardiac Surgery & Transcatheter Interventions trial (FRAILTY-AVR; ClinicalTrials.gov identifier: NCT01845207) comprised 1020 patients (median age, 82 years) who underwent either TAVR or SAVR. The study was conducted throughout 14 centers in the United States, Canada, and France from 2012 to 2016.

The investigators compared the EFT, Fried, Fried+, Rockwood, Short Physical Performance Battery, Bern, and Columbia frailty scales to determine each tool's value in identifying poor outcomes following valve replacement surgery. The EFT is a brief 4-item scale that assesses lower-extremity weakness, cognitive impairment, anemia, and hypoalbuminemia. 

Patients' frailty ranged from 26% to 68%, depending on the scale used. The EFT was the strongest predictor of death and worsening disability at 1 year (adjusted odds ratio [OR] 3.72; 95% CI, 2.54-5.45 and adjusted OR, 2.13; 95% CI, 1.57-2.87, respectively) with a C-statistic improvement of 0.071 (P <.001) and an integrated discrimination improvement of 0.067 (P <.001), specifically related to death. This scale was also the strongest predictor of death at 30 days (adjusted OR 3.29; 95% CI, 1.73-6.26).

Aside from its predictive value, the EFT has the following advantages: it is quick to conduct, it does not require specialized equipment, and its components are actionable and have a high interobserver reliability.

In addition to frailty, atrial fibrillation, oxygen-dependent lung disease, and kidney disease, especially when dialysis-dependent, were also identified as risk factors for poor outcomes following TAVR or SAVR.

The FRAILTY-AVR study addressed the lack of insight into which frailty assessment, if any, to use by “comparing the incremental value of frailty scales in a well powered sample across a broad spectrum of risk and procedure types,” the researchers wrote.

Despite high rates of procedural success and short-term survival in both TAVR and SAVR, the incidence of functional decline and poor patient-centered outcomes at 1 year was 35% in the whole cohort and more than 50% in patients who were frail. These findings highlight the importance of the use of frailty scales in clinical practice to identify those patients unable to sustain long-term improvement following valve replacement procedures. 

Study Limitations

  • Patients in the TAVR group were considered at higher risk than those in the SAVR group.
  • Patients who received TAVR were more likely to be screened and enrolled via clinics with specialized TAVR expertise.
  • In this study, the cognitive impairment section of the EFT was assessed by the Mini-Mental State Examination, which can be time-consuming; a shortened version has since been substituted.
  • Not all surviving patients completed the disability questionnaire at 1 year, so the reported incidence may be lower than the actual rate.

Disclosures: Many of the study authors report financial relationships with pharmaceutical and device companies, including Abbott Vascular, Boston Scientific, Edwards Lifesciences, Medtronic, Roche Diagnostics, and St. Jude Medical, among others.

Reference

Afilalo J, Lauck S, Kim DH, et al. Frailty in older adults undergoing aortic valve replacement. The FRAILTY-AVR Study [published online June 21, 2017]. J Am Coll Cardiol. doi:10.1016/j.jacc.2017.06.024

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