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A brief frailty scale outperformed other ones to identify older patients at higher risk of death and disability following transcatheter aortic valve replacement (TAVR) or surgical aortic valve replacement (SAVR), researchers found.

The Essential Frailty Toolset to be the strongest predictor of:

• Death at 1 year (adjusted OR 3.72, 95% CI 2.54-5.45)
• Worsening disability at 1 year (adjusted OR 2.13, 95% CI 1.57-2.87)
• Death at 30 days (adjusted OR 3.29, 95% CI 1.73-6.26)

Adding this scale to a 1-year mortality model containing the STS-PROM score and procedure type improved the C-statistic by 0.071 -- compared with a 0.004 boost previously reported in the literature when using 5-m gait speed and the Fried scale, according to Jonathan Afilalo, MD, MSc, of Jewish General Hospital in Montreal, Canada, and collaborators in the published online in the Journal of the American College of Cardiology.

The best model that Afilalo's group came up with incorporated the Essential Frailty Toolset and clinical risk factors and had a final C-statistic of 0.813.

"When measured objectively with a validated scale, frailty adds incremental value above existing risk models to predict midterm mortality and progressive disability after an aortic valve procedure," the authors concluded, recommending that the Essential Frailty Toolset be used in this setting.

In their study, death occurred in 2.4% of SAVR and 5.6% of TAVR patients during the first 30 days.

"Although the likelihood of procedural success and short-term survival was very high, the incidence of subsequent functional decline and poor patient-centered outcomes at 1 year was 35% for the entire cohort and >50% for those who were frail," Afilalo and colleagues noted.

FRAILTY-AVR was a prospective study of 1,020 older patients (median age 82) who were enrolled at 14 centers in the U.S., Canada, and France. Patients underwent either TAVR (n=646) or SAVR (n=374), with half of the latter also receiving concomitant coronary artery bypass.

Depending on the frailty scale used -- Fried, Fried+, Rockwood, Short Physical Performance Battery, Bern, Columbia, or Essential Frailty Toolset -- the rate of frailty ranged from 26% to 68% in the study group. The Essential Frailty Toolset is a brief 5-point scale assessing lower-extremity weakness (chair rise ability), cognitive impairment, anemia, and hypoalbuminemia.

"The advantages of the Essential Frailty Toolset, beyond its predictive value, are that it is quick to perform, it does not require specialized equipment, and, importantly, its components have high interobserver reliability and are actionable," according to the investigators.

However, they admitted that evaluating the cognitive impairment domain of the scale was time-consuming over the course of the study; the good news is now there is a shorter Mini-Cog Test in a modified version of the Essential Frailty Toolset.

Limitations to the study include higher baseline risk in TAVR patients -- although similar results were found when restricting analysis to that group -- and the fact that 68 survivors didn't complete the disability questionnaire at 1 year.

"Although the Essential Frailty Toolset is not all-encompassing, it is a well-rooted starting point to test for frailty, and to identify patients in whom further geriatric assessment should be considered to confirm the diagnosis of sarcopenia, malnutrition, dementia, depression, or disability," Afilalo and colleagues maintained.

"Further research is warranted to define the therapeutic and mechanistic implications of this frailty construct, and to validate its utility in other groups of patients with cardiovascular disease."

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