Sunita R Jha1, Malin K Hannu2, Keren Gore3, Sungwon Chang4, Phillip Newton1, Kay Wilhelm5, Christopher S Hayward6, Andrew Jabbour6, Eugene Kotlyar7, Anne Keogh7, Kumud Dhital7, Emily Granger7, Paul Jansz7, Phillip M Spratt8, Elyn Montgomery7, Michelle Harkess7, Peta Tunicliff7, Patricia M Davidson9, Peter S Macdonald10. 1. Heart Transplant Program, St Vincent's Hospital; Centre for Cardiovascular and Chronic Care, Faculty Health, University of Technology Sydney. 2. Heart Transplant Program, St Vincent's Hospital; Department of Occupational Therapy. 3. Department of Occupational Therapy. 4. Centre for Cardiovascular and Chronic Care, Faculty Health, University of Technology Sydney. 5. Consultation Liaison Psychiatry, St Vincent's Hospital; Faculty of Medicine, University of New South Wales. 6. Heart Transplant Program, St Vincent's Hospital; Faculty of Medicine, University of New South Wales; Victor Chang Cardiac Research Institute. 7. Heart Transplant Program, St Vincent's Hospital. 8. Heart Transplant Program, St Vincent's Hospital; Faculty of Medicine, University of New South Wales; Department of Cardiothoracic Surgery, St Vincent's Hospital, Sydney, New South Wales, Australia. 9. Centre for Cardiovascular and Chronic Care, Faculty Health, University of Technology Sydney; Faculty of Nursing, Johns Hopkins University, Baltimore, Maryland. 10. Heart Transplant Program, St Vincent's Hospital; Faculty of Medicine, University of New South Wales; Victor Chang Cardiac Research Institute. Electronic address: peter.macdonald@svha.org.au.
Abstract
BACKGROUND: The aim of this study was to identify whether the addition of cognitive impairment, depression, or both, to the assessment of physical frailty provides better outcome prediction in patients with advanced heart failure referred for heart transplantation (HT). METHODS: Beginning in March 2013, all patients with advanced heart failure referred to our Transplant Unit have undergone a physical frailty assessment using the Fried frailty phenotype. Cognition was assessed with the Montreal Cognitive Assessment and depression with the Depression in Medical Illness questionnaire. We assessed the value of 4 composite frailty measures: physical frailty (PF ≥ 3 of 5 = frailty), "cognitive frailty" (CogF ≥ 3 of 6 = frail), "depressive frailty" (DepF ≥ 3 of 6 = frail), and "cognitive-depressive frailty" (ComF ≥ 3 of 7 = frail) in predicting outcomes. RESULTS: Frailty was assessed in 156 patients (109 men, 47 women), aged 53 ± 13 years, and with a left ventricular ejection fraction of 27% ± 14%. Inclusion of cognitive impairment or depression in the definition of frailty increased the proportion classified as frail from 33% using PF to 42% using ComF. During follow-up, 28 patients died before ventricular assist device implantation or HT. Frailty was associated with significantly lower ventricular assist device- and HT-free survival, with CogF best capturing early mortality: 12-month survival for non-frail and frail cohorts was 81% ± 5% vs 58% ± 10% (p < 0.02) using PF and 85% ± 5% vs 56% ± 9% (p < 0.002) using CogF. Combining the Depression in Medical Illness score with PF or CogF did not strengthen the relationship between frailty and mortality. CONCLUSIONS: The addition of cognitive impairment to the assessment of PF strengthened its capacity to identify advanced heart failure patients referred for HT who are at high risk of early death.
BACKGROUND: The aim of this study was to identify whether the addition of cognitive impairment, depression, or both, to the assessment of physical frailty provides better outcome prediction in patients with advanced heart failure referred for heart transplantation (HT). METHODS: Beginning in March 2013, all patients with advanced heart failure referred to our Transplant Unit have undergone a physical frailty assessment using the Fried frailty phenotype. Cognition was assessed with the Montreal Cognitive Assessment and depression with the Depression in Medical Illness questionnaire. We assessed the value of 4 composite frailty measures: physical frailty (PF ≥ 3 of 5 = frailty), "cognitive frailty" (CogF ≥ 3 of 6 = frail), "depressive frailty" (DepF ≥ 3 of 6 = frail), and "cognitive-depressive frailty" (ComF ≥ 3 of 7 = frail) in predicting outcomes. RESULTS: Frailty was assessed in 156 patients (109 men, 47 women), aged 53 ± 13 years, and with a left ventricular ejection fraction of 27% ± 14%. Inclusion of cognitive impairment or depression in the definition of frailty increased the proportion classified as frail from 33% using PF to 42% using ComF. During follow-up, 28 patients died before ventricular assist device implantation or HT. Frailty was associated with significantly lower ventricular assist device- and HT-free survival, with CogF best capturing early mortality: 12-month survival for non-frail and frail cohorts was 81% ± 5% vs 58% ± 10% (p < 0.02) using PF and 85% ± 5% vs 56% ± 9% (p < 0.002) using CogF. Combining the Depression in Medical Illness score with PF or CogF did not strengthen the relationship between frailty and mortality. CONCLUSIONS: The addition of cognitive impairment to the assessment of PF strengthened its capacity to identify advanced heart failurepatients referred for HT who are at high risk of early death.
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