Frailty Score Predicts 1-Year Mortality But Not Procedural Complications in TAVR

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Frailty is associated with increased mortality 1 year after transcatheter aortic valve replacement (TAVR) in older patients with severe aortic stenosis, though it does not affect the risk of in-hospital complications or 30-day mortality. The findings, based upon a newly developed scoring system to characterize frailty, were published in the September 2012 issue of JACC: Cardiovascular Interventions.

Investigators led by Mathew Williams, MD, of Columbia University Medical Center (New York, NY), assessed 159 patients aged 86 ± 8 years who underwent TAVR at their institution as part of the PARTNER (Placement of AoRTic traNscathetER valve) trial. The researchers designed a frailty score using measurements of gait speed, grip strength, serum albumin, and activities of daily living. Patients were then divided into 2 groups—frail (n = 76) and not frail (n = 83)—based upon whether their scores fell above or below the median value of 5.

Frail patients tended to have longer post-TAVR hospital stays (9 ± 6 days vs. 6 ± 5 days for nonfrail patients; P = 0.004). Periprocedural outcomes did not differ between the frail and nonfrail groups (table 1).

Table 1. In-Hospital Complications and 30-Day Mortality

 

Frail

(n = 76)

Not Frail

(n = 83)

P Value

Life-Threatening or Major Bleedinga

40.8%

31.3%

0.2

Major Vascular Complicationsa

6.6%

3.6%

0.5

Acute Kidney Injury

3.9%

3.6%

0.9

In-Hospital Strokea

0

1.2%

30-Day Mortality

5.3%

4.8%

0.9

a Defined according to Valve Academic Research Consortium criteria.

At 1 year, however, all-cause mortality was higher in frail than nonfrail patients at 22.4% vs. 8.4% (P = 0.01). Even after adjustment for age, access route, Society of Thoracic Surgeons (STS) score, prior PCI, hyperlipidemia, and hemoglobin level, frailty more than tripled the risk of all-cause death (HR 3.51; 95% CI 1.43-8.62; P = 0.006).

Gait speed, grip strength, and impairment in activities of daily living were not linked to survival on univariate analysis, though higher levels of serum albumin were associated with increased mortality (HR 1.51 per quartile; 95% CI 1.03-2.21; P = 0.03).

Improving the Eyeball Test

Ted Feldman, MD, of Evanston Hospital (Evanston, IL), told TCTMD in a telephone interview that the study “validates the growing experience we have that [a frailty index helps] us quantify what historically has been called the eyeball test—just looking at a patient and saying they look frail. Being able to measure it and stratify outcomes is an important step.”

Still, there are issues with the frailty score that need to be resolved before it could be implemented in everyday clinical practice, Josep Rodés-Cabau, MD, and Michael Mok, MBBS, of the Quebec Heart and Lung Institute (Quebec City, Canada), observe in an editorial accompanying the paper.

“Although the prognostic value of a multi-item assessment tool of frailty would probably surpass that of a single-item assessment, the usefulness of each individual component of the frailty score in predicting outcomes after TAVR merits further evaluation in a larger series of patients,” they write, suggesting that the addition of cognitive ability, mood, and mental health might offer a “more complete assessment.”

Though TAVR is typically “associated with marked improvement in functional status and quality of life,” some patients see only mild or no improvement within months of treatment, Drs. Rodés-Cabau and Mok stress. As such, they add, the potential impact of frailty on those outcomes should be addressed in future studies.

Dr. Feldman concluded that it is “hugely important” to incorporate frailty into clinical decision making, especially for TAVR candidates. “We do need a way to stratify patients in terms of frailty,” he said. “An ideal endpoint for this would be to see frailty included in a meaningful way in some new parameter in the STS score. Understanding frailty has already helped us make decisions better.”

Study Details

TAVR was delivered via transfemoral access in 89 patients and transapical access in 70. Half of patients had 3 or more comorbid conditions. Frail patients were more likely to be hyperlipidemic and have previously undergone PCI, and they tended to have lower hemoglobin levels than their nonfrail counterparts. Other baseline characteristics were similar between the 2 groups.

Note: Dr. Williams and several study coauthors are faculty members of the Cardiovascular Research Foundation, which owns and operates TCTMD.

Sources:

1. Green P, Woglom AE, Genereux P, et al. The impact of frailty status on survival after transcatheter aortic valve replacement in older adults with severe aortic stenosis: A single-center experience. J Am Coll Cardiol Intv. 2012;5:974-981.

2. Rodés-Cabau J, Mok M. Working toward a frailty index in transcatheter aortic valve replacement. J Am Coll Cardiol Intv. 2012;5:982-983.

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Frailty Score Predicts 1-Year Mortality But Not Procedural Complications in TAVR

Frailty is associated with increased mortality 1 year after transcatheter aortic valve replacement (TAVR) in older patients with severe aortic stenosis, though it does not affect the risk of in hospital complications or 30-day mortality. The findings, based upon
Disclosures
  • Dr. Williams reports serving as a consultant to Edwards Lifesciences.
  • Dr. Mok reports no relevant conflicts of interest.
  • Dr. Rodés-Cabau reports serving as a consultant for Edwards Lifesciences and St. Jude Medical.
  • Dr. Feldman reports serving as a consultant to and receiving research support from Boston Scientific and Edwards Lifesciences.

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