Healthy Hearts Linked to Lower Risk of Frailty in Old Age

Two newly published observational studies continue to provide evidence of a link between cardiovascular disease and frailty.

The Take Home. Healthy Hearts Linked to Lower Risk of Frailty in Old Age

Patients who reach old age while having an ideal cardiovascular risk profile are less apt to be frail, one study found. In another study, investigators showed frailty to be a dynamic measure in patients treated for coronary artery disease, one that typically follows a U-shaped pattern—while frailty increases during the initial 6 months after intervention, patients tend to improve over time.

“Because we see that frailty is dynamic and can be reduced, it demonstrates that an older person with symptomatic heart disease can benefit in a global sense from various forms of therapy,” lead investigator Elizabeth Freiheit, PhD (University of Calgary, Canada), told TCTMD by email. “If validated and refined in other studies, this might help inform the treatment choices and recovery options made by patients and their physicians.”

Jonathan Afilalo, MD (McGill University, Montreal, Canada), who wrote an editorial accompanying the studies, said there is least one message that clinicians can draw from the data, namely that frailty is a state that is influenced by both physician and patient choices.

“Individuals may choose to forgo physical activity just as their treating physicians may choose to forgo or gloss over nonpharmacological noninterventional therapies,” writes Afilalo. The consequence of these choices, he says, “is accelerated biological aging and frailty.”

The two studies and the editorial were published online May 10 in Circulation: Cardiovascular Quality & Outcomes.

CV Health and Frailty

In the first study, Auxiliadora Graciani, MD (Universidad Autónoma de Madrid, Spain), and colleagues conducted a prospective cohort study of 1,745 people aged 60 or older who were free of cardiovascular disease. Between 2008 and 2010, individuals were recruited and assessed for seven ideal metrics of cardiovascular health: never smoking, being physically active, and having a healthy diet, healthy body mass index, untreated serum cholesterol less than 200 mg/dL, untreated blood pressure less than 140/90 mm Hg, and untreated serum fasting glucose less than 100 mg/dL. Patients were followed for 3.5 years and assessed for incidence frailty, defined as three or more of the five Fried criteria.

Of the study cohort, 25% had zero to one ideal cardiovascular metrics, 29% had two healthy metrics, and 46% had three or more healthy metrics at baseline. During follow-up, the researchers identified 117 cases of incident frailty.

After adjusting for potential confounders, individuals with better cardiovascular health had a lower risk of frailty. Compared with having zero to one ideal metric, people with two metrics and those with three or more metrics had significantly reduced risk of frailty (see table).

The researchers also assigned individuals a cardiovascular metric score, awarding a score of zero to a poor metric, 1 to an intermediate metric, and 2 to an ideal metric. Overall, they found an inverse dose-response relationship between higher scores and risk for frailty.

Table. Healthy Hearts Linked to Lower Risk of Frailty in Old Age

Among the metrics examined, the greatest reduction in frailty risk was among individuals who were physically active versus inactive (HR 0.49; 95% CI, 0.24-0.97) and those with a body mass index of less than 25 compared with obesity (HR 0.43; 95% CI, 0.22-0.85).

CAD Treatment and Frailty

In the second study, Freiheit and colleagues assessed frailty in 374 patients with coronary artery disease undergoing nonemergent cardiac catheterization followed by treatment: 128 had CABG, 150 PCI, and 96 received medical therapy alone. Median age was 71.4 years. Each patient was assigned a frailty index (FI) score at baseline and at 6, 12, and 30 months. Decreases in FI scores indicated improvement.

The researchers observed that in the overall group, FI scores declined at the 6-month mark but increased again at the 12-month and 30-month measurements. Although both men and women in the study had FI scores that followed this U-shaped trend, women had numerically increased FI scores compared with men.

Patients assigned to PCI experienced a similar U-shape trend in their FI score. However, patients assigned to CABG or medical therapy had no initial reduction in FI score at the 6-month follow-up. Patients aged less than 75 were able to sustain the reductions in FI score seen at 6 months throughout the 30-month study period. In contrast, patients aged less than 75 assigned to medical therapy had initial reductions at 6 months and 12 months, with scores increasing higher than baseline by the 30-month follow-up.

Wider Relevance

Both Graciani and Freiheit said that the results of these studies reflect that clinicians should consider frailty in their decision making when it comes to prevention strategies and treatment of older patients.

For Graciani, population-wide primordial prevention is a key strategy for preventing frailty and reducing the undesired consequences of population aging.

“In contrast to primary CVD prevention, which requires continuous healthcare, primordial intervention through appropriate social changes could definitively minimize CVD burden without extensive provision of health services,” Graciani told TCTMD in an email. “Our results point to the predominant role of behavioral over biological CVD risk factors in frailty prevention. Maintaining an active life and a normal BMI entails keeping anthropological ‘normality’ throughout adult life, because most infants and children are physically active and have a healthy weight.”

In situations where interventions are required, clinicians are continuously seeking ways to better differentiate those patients who may have difficulty recovering from a major procedure, Freiheit said.

“Traditional cardiovascular risk models were derived from and are used to assess mortality risk. They use only clinical and angiographic indicators and are largely based on age,” she said. “However, in addition to mortality and hospitalization, frailty can predict decline in important quality-of-life outcomes such as activities of daily living and functional status, and may help to identify potentially modifiable determinants of poor health outcomes.”

Michael W. Rich, MD (Washington University School of Medicine, St. Louis, MO), agreed that it is important for cardiologists to be able to accurately recognize frailty when caring for older patients with cardiovascular disease. Although the results of these two studies are not surprising, they add to a “growing body of literature attesting to the bidirectional linkage between frailty and CVD,” Rich told TCTMD in an email.

Rich pointed out that the populations of both studies were relatively young, with few patients aged older than 80, and in relatively good health, with few noncardiac comorbidities. “Since the prevalence of frailty increases exponentially with age, it is essential that future studies include greater representation of the ‘oldest old,’ ie, those over 80-85 years of age,” Rich said.


  • Graciani A, Garcia-Esquinas E Lopez-Garcia E, et al. Ideal cardiovascular health and risk of frailty in older adults. Cir Cardiovasc Qual Outcomes. 2016;Epub ahead of print.
  • Freiheit EA, Hogan DB, Patten SB, et al. Frailty trajectories after treatment for coronary artery disease in older patients. Cir Cardiovasc Qual Outcomes. 2016;Epub ahead of print.
  • Afilalo J. Road to Frailty is paved with good intentions. Cir Cardiovasc Qual Outcomes. 2016;Epub ahead of print.

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  • Funding for the work by Graciani and colleagues was obtained from the Spanish Government FIS grants 12/1166, 13/00288, and 13/02321 (Instituto de Salud Carlos III and FEDER/FSE), the FRAILOMIC Initiative (EU FP7-HEALTH-2012-Proposal no. 305483-2), and the ATHLOS project.
  • Funding for the study by Freiheit and colleagues was received from the Canadian Institutes of Health Research Institute of Aging (IAO-63151), the M.S.I. Foundation (no. 810), and the Brenda Strafford Foundation Chair for Geriatric Medicine.
  • The paper contains no statement regarding conflicts of interest for Jones.
  • Graciani, Freiheit, and Afilalo report no relevant conflicts of interest.