Author + information
- aDepartment of Medicine, Sidney Kimmel Medical College at Thomas Jefferson University, Philadelphia, Pennsylvania
- bGeriatric Cardiology Section in the Divisions of Cardiology and Geriatrics, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
- cGeriatric Research, Education, and Clinical Center, VA Pittsburgh Healthcare System, Pittsburgh, Pennsylvania
- dDepartment of Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania
- ↵∗Reprint requests and correspondence:
Dr. Daniel E. Forman, Geriatric Cardiology Section, University of Pittsburgh, 3471 Fifth Avenue, Suite 500, Pittsburgh, Pennsylvania 15213.
In this issue of JACC: Heart Failure, Pulignano et al. (1) present a compelling assessment of gait speed in older heart failure (HF) patients; they show that gait speed adds the capacity to predict mortality and hospitalization beyond conventional cardiac prognostic markers. It is most striking that a non-cardiorespiratory index (usual walking speed over a very short distance) increases the capacity to demarcate risk and instability among HF patients. However, it resonates with an abundance of published reports extending over decades consistently demonstrating the utility of gait speed to predict a wide range of clinical events in older adults such that there is a strong continuous association between progressively slower gait speed and loss of functional independence (e.g., disability, nursing home placement), hospitalization, and mortality (2,3). Other studies have linked frailty assessments, particularly gait speed, to cardiovascular disease, including aortic valve disease, HF, and coronary heart disease (4). In HF specifically, findings are consistent with the general older population, with slow gait speed independently associated with disability, hospitalization, and mortality (5–7).
In the present study, gait speed was assessed in 331 older patients (mean age = 78 years) with a HF hospitalization in the past year. As with prior studies of older patients with HF (8,9), there was a high prevalence of multimorbidity and adverse clinical events, including high rates of 1-year all-cause hospitalization (60%) and death (24%). In multivariable analyses, gait speed was found to independently predict mortality and hospitalization (HF and all-cause). Even after applying a previously validated HF risk score (3C-HF) based on more conventional HF risk factors (e.g., New York Heart Association functional class, atrial fibrillation, HF medications), gait speed further refined risk stratification, identifying relatively high- and low-risk groups across the spectrum of risk as initially determined by this HF model.
This study provides further evidence for the clinical importance of global risk that is not contingent on a specific disease state, but which is instead more indicative of aggregate health. This concept is particularly relevant to older patients with HF, who on average have 5 other chronic medical conditions and are far more likely to be hospitalized for reasons unrelated to heart disease than they are for HF (9–11). Even among those who experience a HF hospitalization, most subsequent clinical events occur for other reasons (8). Thus, a better assessment of global risk in HF seems particularly important to guide care amidst today’s health care dynamics, both in terms of care quality and cost, specifically in regard to Medicare penalties and bundled payments (12).
Frailty assessments are a promising means to estimate such global risk, yet the preferred frailty assessment remains controversial (13). There is a spectrum of validated approaches ranging from a simple single-item assessment, such as gait speed, to progressively broader assessments of frailty incorporating other clinical domains, comorbidities and degree of functional independence as would be included in a comprehensive geriatric evaluation (4,13). Although consensus regarding the “best” frailty measure remains elusive, frailty is still widely accepted as an important non–disease-specific measure with substantial clinical relevance. Such measures may help refine estimates of prognosis by reflecting novel elements of global risk related to the cumulative and heterogeneous impact of aging, multimorbidity, and disability that are not captured in more conventional HF prognostic indices and models. As the conceptual framework surrounding frailty evolves, we may better appreciate how to integrate different approaches to frailty assessment into clinical practice in a complementary fashion so as to inform and guide clinical decision making.
When considering how this might be practically accomplished amidst clinical exigencies, gait speed offers several distinctive advantages. It is relatively simple to assess, and it can be performed quickly and safely in a wide range of settings (clinic, hospital, home) at minimal expense. Furthermore, it evokes an intuitive quality because ambulation is fundamental to maintaining functional independence and quality of life for most older adults. However, despite such seeming simplicity, methodological details (distance walked, standstill vs. moving start, etc.) significantly impact the measured gait speed, and further efforts to establish a single, widely agreed upon approach and standard are needed (2,14).
Once measures of frailty are obtained, it is also not clear how the information is best utilized. One potential application is to use frailty to determine when a particular procedure or therapy would be “futile.” However, frailty status can be dynamic, and the degree to which frailty may be treated and potentially modified has yet to be determined (15). Nonetheless, better understanding of aggregate risks allows for a more informed discussion of risks and benefits, facilitating a process of shared decision making. Beyond informing prognosis and clinic decisions, gait speed may also be used as screening tool to trigger a more comprehensive assessment of frailty-related factors known to impact outcomes. Ongoing investigations will help determine whether tailored interventions based on frailty assessments can improve clinical outcomes and quality of life. Similarly, studies are exploring utility of expanded models of pre-habilitation, rehabilitation, nutrition, and other interventions to better surmount the risks associated with frailty once it is recognized (16).
Studies such as the one by Pulignano et al. (1) are essential to advancing our understanding of the value of frailty assessments in older patients with HF. We look forward to future work in this field with the hope of identifying new ways to improve patient-centered care for today’s growing population of vulnerable patients.
↵∗ Editorials published in JACC: Heart Failure reflect the views of the authors and do not necessarily represent the views of JACC: Heart Failure or the American College of Cardiology.
Dr. Forman is supported in part by National Institute on Aging (NIA) grant P30 AG024827 and VA RR&D F0834-R. Dr. Reeves is supported in part by NIA grant R01AG045551; and has received a research grant from Thoratec Corporation. Dr. Forman has reported that he has no relationships relevant to the contents of this paper to disclose.
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