The Clinical Frailty Scale
2017; Lippincott Williams & Wilkins; Volume: 135; Issue: 21 Linguagem: Inglês
10.1161/circulationaha.116.025958
ISSN1524-4539
Autores Tópico(s)Health Systems, Economic Evaluations, Quality of Life
ResumoHomeCirculationVol. 135, No. 21The Clinical Frailty Scale Free AccessEditorialPDF/EPUBAboutView PDFView EPUBSections ToolsAdd to favoritesDownload citationsTrack citationsPermissions ShareShare onFacebookTwitterLinked InMendeleyReddit Jump toFree AccessEditorialPDF/EPUBThe Clinical Frailty ScaleUpgrade Your Eyeball Test Jonathan Afilalo, MD, MSc Jonathan AfilaloJonathan Afilalo From Centre for Clinical Epidemiology, Lady Davis Institute, Mc-Gill University, Montreal, Quebec, Canada; and Division of Cardiology, Jewish General Hospital, McGill University, Montreal, Quebec, Canada. Originally published16 Mar 2017https://doi.org/10.1161/CIRCULATIONAHA.116.025958Circulation. 2017;135:2025–2027Other version(s) of this articleYou are viewing the most recent version of this article. Previous versions: January 1, 2017: Previous Version 1 Article, see p 2013With the emergence of transcatheter aortic valve replacement (TAVR) as a therapeutic option to treat high-risk older adults with aortic stenosis, the geriatric concept of frailty has assumed mainstream relevance for cardiovascular practitioners. We have eagerly adopted tools to objectify the definition of frailty and accordingly discern good and bad candidates among a pool of complex octogenarians with multiple chronic conditions, a daunting yet mission-critical task. Initial studies published during the first half of this decade revealed that frailty status was one of the top predictors of midterm mortality and incident disability after TAVR,1 leading to its integration in clinical care pathways and predictive risk models. The encouraging findings from small single-center studies are now being validated in larger multicenter registries and trials, affirming the strengths and uncovering the limitations of various frailty assessment tools.In this issue of Circulation, Shimura et al2 have presented an analysis of the prospective OCEAN-TAVI registry (Optimized Transcatheter Valvular Intervention-Transcatheter Aortic Valve Implantation) encompassing 1215 high-risk patients who underwent TAVR at 9 centers in Japan between 2013 and 2016. For the purposes of this analysis, the primary predictor variable was Rockwood's Clinical Frailty Scale (CFS) ascertained by trained medical professionals who had direct contact with the patients and their families before TAVR. The CFS is a semiquantitative tool that provides a global score ranging from 1 (very fit) to 9 (terminally ill) to reflect the following domains: disability for basic and instrumental activities of daily living, mobility, activity, energy, and disease-related symptoms. Higher CFS scores were associated with slightly older age, a greater proportion of women, higher New York Heart Association class and brain natriuretic peptide level, lower serum albumin and hemoglobin, and slower average gait speed. Of note, gait speed was not measured in 23% of patients, which is more than would be expected. Comorbidities, left ventricular function, and aortic stenosis severity were generally similar across CFS categories, with the exception of previous stroke, which was more common in frail patients.Attraction toward the CFS is justified by its ease-of-use in the clinical setting (because there is no need for stopwatches, dynamometers, or other specialized equipment or personnel), and its track record in the geriatric literature as a predictor of mortality and institutionalization.3 A word of caution: although the CFS may be touted as a structured eyeball test, it does require data collection beyond that which could be gleamed from a superficial end-of-the-bed-o-gram. For the cardiovascular practitioner, this entails (at a minimum) watching patients mobilize and inquiring about their habitual physical activity and ability to independently perform tasks such as bathing, dressing, housework, going up stairs, going out alone, going shopping, taking care of finances, taking medications, and preparing meals. One of the limitations of the CFS is that it amalgamates several domains and may not be as actionable as phenotype-oriented frailty scales focused on sarcopenia. Many experts, and I would agree, prefer to untangle the concepts of frailty and disability.4,5 Moreover, because the CFS is heavily weighted by the patient's level of disability, it is unclear whether the CFS offers superior or redundant value in comparison with disability scales such as the Katz Index or the Older American Resources and Services scale.6,7The authors' findings were lucidly conveyed and can be summarized as follows. First, they reported a univariate association between the CFS and post-TAVR complications; this was likely confounded by the higher risk profile of frail patients and their greater propensity to undergo TAVR via a nonfemoral access route. Second, they reported a trend toward an association between the CFS and 30-day mortality; only 23 short-term deaths were recorded and the authors acknowledged that their study was underpowered to definitively address this end point. Third, and most important, they observed a robust association between the CFS and 1-year mortality, with 107 midterm deaths recorded. Patients with CFS scores of ≥7, notwithstanding the modest number of patients in this group denoted by "severe frailty and complete dependence for personal care," faced the highest risk of 1-year mortality (45%), whereas CFS scores of 1 to 6 faced a lower risk (7%–18%). It is interesting to note that all 48 patients with CFS scores of ≥7 were physically unable to complete the gait speed test, in line with the notion that being unable to walk may be more telling than being a slow walker in this population. Slow walkers are ubiquitous in TAVR clinics; given 10 high-risk TAVR patients, 7 would be expected to walk 5 meters slower than the 6 second cutoff, 2 would walk faster, and 1 would not be able to complete the test.8To externally validate Shimura's results, the prevalence and predictive value of the CFS were explored in the FRAILTY-AVR study (Frailty in Aortic Valve Replacement) data set,9 which includes 646 older adults undergoing TAVR (and 374 older adults undergoing surgical aortic valve replacement that were not considered for this comparative analysis). As shown in the Figure, subdivided as CFS 1 to 3, CFS 4, CFS 5, CFS 6, and CFS ≥7, the respective prevalence was 31%, 34%, 21%, 11%, and 3%, and the 1-year mortality was 8%, 17%, 29%, 29%, and 30%. Adjusting for the same covariates, the odds ratio for 1-year mortality per CFS category was 1.41 (95% confidence interval, 1.15–1.75) in FRAILTY-AVR in comparison with 1.43 (95% confidence interval, 1.12–1.70) in OCEAN-TAVI. The consistency of the results across data sets supports the external validity of the CFS in the TAVR population. As a caveat, a large step-up in risk was observed for patients who had CFS scores of ≥7 in OCEAN-TAVI, whereas a more gradual increase in risk was observed in FRAILTY-AVR with a plateau above a cutoff of ≥5. The consistency of the study-level summary statistics should not be equated with reliability of the CFS at the individual patient level. Interrater reliability was not assessed by Shimura et al and appears to be moderate based on a κ of 0.76 (95% confidence interval, 0.68–0.84) in one published study.8 Thus, it seems prudent to await the results of forthcoming studies investigating the reliability of the CFS before widely recommending its use for clinical decision making in individual patients.Download figureDownload PowerPointFigure. Comparison of CFS results in the OCEAN-TAVI and FRAILTY-AVR studies. CFS indicates Clinical Frailty Scale; FRAILTY-AVR, Frailty in Aortic Valve Replacement; and OCEAN-TAVI, Optimized Transcatheter Valvular Intervention.In summary, this well-conducted study by Shimura et al adds substantively to our understanding of geriatric risk prediction in TAVR candidates. Although the CFS tool is less amenable than others (such as the short physical performance battery or psoas muscle area10) to identifying potentially reversible cases of frailty that have evidence of sarcopenia and may improve with exercise and nutrition interventions,11 it may be more amenable to forecasting futile cases that have progressed to the end stage of disability.12 Final results of the FRAILTY-AVR study are awaited to clarify the relative merits of each frailty assessment tool in older adults undergoing transcatheter and surgical aortic valve procedures. Regardless of the tool used, clinicians should be alerted to the following red flags for futility when a high-risk patient is referred for TAVR13: being unable to complete a short-distance gait speed test or chair rise test, being dependent for most basic activities of daily living, being malnourished with low serum albumin and unintentional weight loss, being significantly anemic (in the absence of a clearly reversible cause), having advanced dementia, having oxygen-dependent lung disease, and having severe chronic kidney or liver disease. Our collective experience, reinforced and enriched by the current study, has taught us that the resounding patient-centered benefits of TAVR may be muted in the presence of these red flags.Sources of FundingDr Afilalo is supported by the Canadian Institutes of Health Research, the Heart & Stroke Foundation of Canada, and the Fonds de Recherche du Québec en Santé.DisclosuresNone.FootnotesThe opinions expressed in this article are not necessarily those of the editors or of the American Heart Association.Circulation is available at http://circ.ahajournals.orgCorrespondence to: Jonathan Afilalo, MD, MSc, 3755 Cote Ste Catherine Road, E-222, Montreal, Quebec H3T 1E2. E-mail [email protected]References1. Afilalo J, Alexander KP, Mack MJ, Maurer MS, Green P, Allen LA, Popma JJ, Ferrucci L, Forman DE. Frailty assessment in the cardiovascular care of older adults.J Am Coll Cardiol. 2014; 63:747–762. doi: 10.1016/j.jacc.2013.09.070.CrossrefMedlineGoogle Scholar2. Shimura T, Yamamoto M, Kano S, Kagase A, Kodama A, Koyama Y, Tsuchikane E, Suzuki T, Otsuka T, Kohsaka S, Tada N, Yamanaka F, Naganuma T, Araki M, Shirai S, Watanabe Y, Hayashida K, on behalf of the OCEAN-TAVI Investigators. Impact of the clinical frailty scale on outcomes after transcatheter aortic valve replacement.Circulation. 2017; 135:2013–2024. doi: 10.1161/CIRCULATIONAHA.116.025630.LinkGoogle Scholar3. Rockwood K, Song X, MacKnight C, Bergman H, Hogan DB, McDowell I, Mitnitski A. A global clinical measure of fitness and frailty in elderly people.CMAJ. 2005; 173:489–495. doi: 10.1503/cmaj.050051.CrossrefMedlineGoogle Scholar4. Fried LP, Ferrucci L, Darer J, Williamson JD, Anderson G. Untangling the concepts of disability, frailty, and comorbidity: implications for improved targeting and care.J Gerontol A Biol Sci Med Sci. 2004; 59:255–263.CrossrefMedlineGoogle Scholar5. Abellan van Kan G, Rolland Y, Bergman H, Morley JE, Kritchevsky SB, Vellas B. The I.A.N.A Task Force on frailty assessment of older people in clinical practice.J Nutr Health Aging. 2008; 12:29–37.CrossrefMedlineGoogle Scholar6. Katz S, Ford AB, Moskowitz RW, Jackson BA, Jaffe MW. Studies of illness in the aged. The index of ADL: a standardized measure of biological and psychosocial function.JAMA. 1963; 185:914–919.CrossrefMedlineGoogle Scholar7. Fillenbaum GG, Smyer MA. The development, validity, and reliability of the OARS multidimensional functional assessment questionnaire.J Gerontol. 1981; 36:428–434.CrossrefMedlineGoogle Scholar8. Alfredsson J, Stebbins A, Brennan JM, Matsouaka R, Afilalo J, Peterson ED, Vemulapalli S, Rumsfeld JS, Shahian D, Mack MJ, Alexander KP. Gait speed predicts 30-day mortality after transcatheter aortic valve replacement: results from the Society of Thoracic Surgeons/American College of Cardiology Transcatheter Valve Therapy Registry.Circulation. 2016; 133:1351–1359.LinkGoogle Scholar9. Afilalo J, Lauck S, Kim DH, Lefèvre T, Piazza N, Lachapelle K, Martucci G, Lamy A, Labinaz M, Peterson MD, Arora RC, Noiseux N, Rassi A, Palacios I, Genereux P, Lindman BR, Asgar A, Kim CA, Trnkus A, Morais JA, Langlois Y, Rudski LG, Popma JJ, Webb JG, Perrault LP. Frailty in older adults undergoing transcatheter or surgical aortic valve replacement: the Frailty-AVR Study.J Am Coll Cardiol. 2016; 67:8.CrossrefGoogle Scholar10. Mamane S, Mullie L, Piazza N, Martucci G, Morais J, Vigano A, Levental M, Nelson K, Lange R, Afilalo J. Psoas muscle area and all-cause mortality after transcatheter aortic valve replacement: the Montreal-Munich Study.Can J Cardiol. 2016; 32:177–182. doi: 10.1016/j.cjca.2015.12.002.CrossrefMedlineGoogle Scholar11. Bibas L, Levi M, Bendayan M, Mullie L, Forman DE, Afilalo J. Therapeutic interventions for frail elderly patients: part I. Published randomized trials.Prog Cardiovasc Dis. 2014; 57:134–143. doi: 10.1016/j.pcad.2014.07.004.CrossrefMedlineGoogle Scholar12. Lindman BR, Alexander KP, O'Gara PT, Afilalo J. Futility, benefit, and transcatheter aortic valve replacement.JACC Cardiovasc Interv. 2014; 7:707–716. doi: 10.1016/j.jcin.2014.01.167.CrossrefMedlineGoogle Scholar13. Arnold SV, Afilalo J, Spertus JA, Tang Y, Baron SJ, Jones PG, Reardon MJ, Yakubov SJ, Adams DH, Cohen DJ; US CoreValve Investigators. Prediction of poor outcome after transcatheter aortic valve replacement.J Am Coll Cardiol. 2016; 68:1868–1877. doi: 10.1016/j.jacc.2016.07.762.CrossrefMedlineGoogle Scholar Previous Back to top Next FiguresReferencesRelatedDetailsCited By Sepúlveda M, Arauna D, García F, Albala C, Palomo I and Fuentes E (2022) Frailty in Aging and the Search for the Optimal Biomarker: A Review, Biomedicines, 10.3390/biomedicines10061426, 10:6, (1426) Wu X, Zhang T, Zhang Y, She Y, Wang L, Gao Y, Deng Y, Chen M, He Y, Chen X, Hao Q, Yue J and Dong B (2022) Natural population cohort study on long-lived adults: West China longevity and ageing procedure (WCLAP), BMJ Open, 10.1136/bmjopen-2021-055407, 12:6, (e055407), Online publication date: 1-Jun-2022. Vahanian A, Beyersdorf F, Praz F, Milojevic M, Baldus S, Bauersachs J, Capodanno D, Conradi L, De Bonis M, De Paulis R, Delgado V, Freemantle N, Gilard M, Haugaa K, Jeppsson A, Jüni P, Pierard L, Prendergast B, Rafael Sádaba J, Tribouilloy C and Wojakowski W (2022) Guía ESC/EACTS 2021 sobre el diagnóstico y tratamiento de las valvulopatías, Revista Española de Cardiología, 10.1016/j.recesp.2021.11.023, 75:6, (524.e1-524.e69), Online publication date: 1-Jun-2022. Vahanian A, Beyersdorf F, Praz F, Milojevic M, Baldus S, Bauersachs J, Capodanno D, Conradi L, De Bonis M, De Paulis R, Delgado V, Freemantle N, Gilard M, Haugaa K, Jeppsson A, Jüni P, Pierard L, Prendergast B, Sádaba J, Tribouilloy C, Wojakowski W, Neumann F, Myers P, Abdelhamid M, Achenbach S, Asteggiano R, Barili F, Borger M, Carrel T, Collet J, Foldager D, Habib G, Hassager C, Irs A, Iung B, Jahangiri M, Katus H, Koskinas K, Massberg S, Mueller C, Nielsen J, Pibarot P, Rakisheva A, Roffi M, Rubboli A, Shlyakhto E, Siepe M, Sitges M, Sondergaard L, Sousa-Uva M, Tarantini G, Zamorano J, Praz F, Milojevic M, Baldus S, Bauersachs J, Capodanno D, Conradi L, De Bonis M, De Paulis R, Delgado V, Freemantle N, Gilard M, Haugaa K, Jeppsson A, Jüni P, Pierard L, Prendergast B, Sádaba J, Tribouilloy C, Wojakowski W, Benchabi Y, Chilingaryan A, Metzler B, Rustamova Y, Shumavets V, Lancellotti P, Smajic E, Trendafilova-Lazarova D, Samardzic J, Karakyriou M, Palecek T, Sanchez Dahl J, Meshaal M, Palm K, Virtanen M, Bouleti C, Bakhutashvili Z, Achenbach S, Boutsikou M, Kertész A, Danielsen R, Topilsky Y, Golino P, Tuleutayev R, Elezi S, Kerimkulov A, Rudzitis A, Glaveckaite S, Sow R, Demarco D, Bulatovic N, Aouad A, van den Brink R, Antova E, Beitnes J, Ochala A, Ribeiras R, Vinereanu D, Irtyuga O, Ivanovic B, Simkova I, González Gómez A, Sarno G, Pedrazzini G, Bsata W, Zakhama L, Korkmaz L, Cherniuk S, Khanji M and Sharipov I (2021) 2021 ESC/EACTS Guidelines for the management of valvular heart disease, European Heart Journal, 10.1093/eurheartj/ehab395, 43:7, (561-632), Online publication date: 12-Feb-2022. Vahanian A, Beyersdorf F, Praz F, Milojevic M, Baldus S, Bauersachs J, Capodanno D, Conradi L, De Bonis M, De Paulis R, Delgado V, Freemantle N, Haugaa K, Jeppsson A, Jüni P, Pierard L, Prendergast B, Sádaba J, Tribouilloy C and Wojakowski W (2022) 2021 ESC/EACTS Guidelines for the management of valvular heart disease, EuroIntervention, 10.4244/EIJ-E-21-00009, 17:14, (e1126-e1196) Patel K, Treibel T, Scully P, Fertleman M, Searle S, Davis D, Moon J and Mullen M (2022) Futility in Transcatheter Aortic Valve Implantation: A Search for Clarity, Interventional Cardiology: Reviews, Research, Resources, 10.15420/icr.2021.15, 17 Padkins M, Breen T, Anavekar N, Barsness G, Kashani K and Jentzer J (2020) Association Between Albumin Level and Mortality Among Cardiac Intensive Care Unit Patients, Journal of Intensive Care Medicine, 10.1177/0885066620963875, 36:12, (1475-1482), Online publication date: 1-Dec-2021. Beyersdorf F, Vahanian A, Milojevic M, Praz F, Baldus S, Bauersachs J, Capodanno D, Conradi L, De Bonis M, De Paulis R, Delgado V, Freemantle N, Gilard M, Haugaa K, Jeppsson A, Jüni P, Pierard L, Prendergast B, Sádaba J, Tribouilloy C, Wojakowski W, Neumann F, Myers P, Abdelhamid M, Achenbach S, Asteggiano R, Barili F, Borger M, Carrel T, Collet J, Foldager D, Habib G, Hassager C, Irs A, Iung B, Jahangiri M, Katus H, Koskinas K, Massberg S, Mueller C, Nielsen J, Pibarot P, Rakisheva A, Roffi M, Rubboli A, Shlyakhto E, Siepe M, Sitges M, Sondergaard L, Sousa-Uva M, Tarantini G, Zamorano J, Praz F, Milojevic M, Baldus S, Bauersachs J, Capodanno D, Conradi L, De Bonis M, De Paulis R, Delgado V, Freemantle N, Gilard M, Haugaa K, Jeppsson A, Jüni P, Pierard L, Prendergast B, Sádaba J, Tribouilloy C and Wojakowski W (2021) 2021 ESC/EACTS Guidelines for the management of valvular heart disease, European Journal of Cardio-Thoracic Surgery, 10.1093/ejcts/ezab389, 60:4, (727-800), Online publication date: 22-Oct-2021. Calabrò P, Gragnano F, Niccoli G, Marcucci R, Zimarino M, Spaccarotella C, Renda G, Patti G, Andò G, Moscarella E, Mancone M, Cesaro A, Giustino G, De Caterina R, Mehran R, Capodanno D, Valgimigli M, Windecker S, Dangas G, Indolfi C and Angiolillo D (2021) Antithrombotic Therapy in Patients Undergoing Transcatheter Interventions for Structural Heart Disease, Circulation, 144:16, (1323-1343), Online publication date: 19-Oct-2021. Chotalia M, Ali M, Alderman J, Kalla M, Parekh D, Bangash M and Patel J (2021) Right Ventricular Dysfunction and Its Association With Mortality in Coronavirus Disease 2019 Acute Respiratory Distress Syndrome*, Critical Care Medicine, 10.1097/CCM.0000000000005167, 49:10, (1757-1768), Online publication date: 1-Oct-2021. Komici K, Gnemmi I, Bencivenga L, Vitale D, Rengo G, Di Stefano A and Eleuteri E (2020) Impact of Galectin-3 Circulating Levels on Frailty in Elderly Patients with Systolic Heart Failure, Journal of Clinical Medicine, 10.3390/jcm9072229, 9:7, (2229) Michel J, Pellegrini C, Rheude T, von Scheidt M, Trenkwalder T, Elhmidi Y, Mayr N, Brecker S, Kasel A, Kastrati A, Schunkert H, Husser O, Bleiziffer S and Hengstenberg C (2020) The Clinical Impact of Psoas Muscle Cross-Sectional Area on Medium-Term Mortality After Transcatheter Aortic Valve Implantation, Heart, Lung and Circulation, 10.1016/j.hlc.2019.05.095, 29:6, (904-913), Online publication date: 1-Jun-2020. Piankova P and Afilalo J (2020) Prevalence and Prognostic Implications of Frailty in Transcatheter Aortic Valve Replacement, Cardiology Clinics, 10.1016/j.ccl.2019.09.011, 38:1, (75-87), Online publication date: 1-Feb-2020. Vitale C and Uchmanowicz I (2019) Frailty in patients with heart failure, European Heart Journal Supplements, 10.1093/eurheartj/suz238, 21:Supplement_L, (L12-L16), Online publication date: 1-Dec-2019. van Oorschot B and Hartmannsgruber J (2019) Erfassung von Gebrechlichkeit bei betagten Patienten in der RadioonkologieDocumentation of frailty in aged patients in radio-oncology, Der Onkologe, 10.1007/s00761-019-0586-1, 25:9, (768-775), Online publication date: 1-Sep-2019. Steinvil A, Buchanan K, Kiramijyan S, Bond E, Rogers T, Koifman E, Shults C, Xu L, Torguson R, Okubagzi P, Pichard A, Satler L, Ben-Dor I and Waksman R (2018) Utility of an additive frailty tests index score for mortality risk assessment following transcatheter aortic valve replacement, American Heart Journal, 10.1016/j.ahj.2018.01.007, 200, (11-16), Online publication date: 1-Jun-2018. Rogers T, Alraies M, Moussa Pacha H, Bond E, Buchanan K, Steinvil A, Gai J, Torguson R, Ben-Dor I, Satler L and Waksman R (2018) Clinical Frailty as an Outcome Predictor After Transcatheter Aortic Valve Implantation, The American Journal of Cardiology, 10.1016/j.amjcard.2017.12.035, 121:7, (850-855), Online publication date: 1-Apr-2018. Lauck S, Kwon J, Wood D, Baumbusch J, Norekvål T, Htun N, Stephenson L and Webb J (2017) Avoidance of urinary catheterization to minimize in-hospital complications after transcatheter aortic valve implantation: An observational study, European Journal of Cardiovascular Nursing, 10.1177/1474515117716590, 17:1, (66-74), Online publication date: 1-Jan-2018. Yamamoto M, Shimura T and Hayashida K (2017) Response by Yamamoto et al to Letter Regarding Article, "Impact of the Clinical Frailty Scale on Outcomes After Transcatheter Aortic Valve Replacement", Circulation, 136:20, (1987-1988), Online publication date: 14-Nov-2017.Afilalo J and Forman D (2017) Gait Speed Assessment in Transcatheter Aortic Valve Replacement, Circulation: Cardiovascular Interventions, 10:9, Online publication date: 1-Sep-2017. May 23, 2017Vol 135, Issue 21 Advertisement Article InformationMetrics © 2017 American Heart Association, Inc.https://doi.org/10.1161/CIRCULATIONAHA.116.025958PMID: 28302750 Originally publishedMarch 16, 2017 Keywordstranscatheter aortic valve replacementEditorialsgeriatric assessmentfrail elderlyPDF download Advertisement
Referência(s)