Frailty ups readmission after CIED implantation

Among older adults, frailty appears to aggravate the risk of hospital readmission after cardiac implantable electrical device (CIED) implantation, according to a recent study.

Of 101 participants (mean age 75.8 years, 37.4 percent women), 63.4 percent had pacemakers, while 19.8 percent and 16.8 percent received implantable cardioverter defibrillators (ICD) and cardiac resynchronization therapy (CRT), respectively.

The proportions of patients with and without frailty were nearly balanced (47.5 percent and 52.5 percent, respectively). [PLoS One 2022;doi:10.1371/journal.pone.0277115]

Over a 1-year follow-up period, nine patients were eventually readmitted, all of which were due to exacerbation of heart failure. The resulting readmission rate was 8.9 percent, which was higher in patients with vs without frailty (20.8 percent vs 1.9 percent). The average time to readmission was 68.0 days; none of the patients died.

Fully adjusted Cox proportional hazards regression analysis revealed that frailty was the only significant and independent predictor of readmission (hazard ratio [HR], 6.92, 95 percent confidence interval [CI], 0.84–56.62; p=0.03). Meanwhile, having heart failure with reduced ejection fraction was of borderline significance (HR, 3.96, 95 percent CI, 0.97–16.11; p=0.05).

“The results of our multivariate analysis showed that frailty was significantly associated with readmission within a 1-year period,” the researchers said, adding that “these findings provide valuable insights for early efforts aimed at preventing readmission, which may be predicted prior to CIED surgery based on modified frailty index (mFI) results.”

These findings were fully confirmed by Kaplan-Meier curve analysis, which showed that the cumulative 1-year probability of readmission was greater in frail patients (p<0.05).

Frailty domains

Looking at the individual items comprising mFI, the researchers noted that specific subdomains drove overall frailty among device users.

For instance, frail adults were significantly more likely to report nonindependence in activities of daily living and specific comorbidities such as diabetes mellitus, congestive heart failure, myocardial infarction, and percutaneous coronary intervention. In contrast, other comorbid conditions like hypertension, cerebrovascular accident-related findings, sensory impairments, and chronic obstructive pulmonary disease were not significant drivers of frailty.

There were also other notable background differences between patients with vs without frailty. For instance, left ventricular ejection fraction was significantly lowered in the former group (49.3 percent vs 61.2 percent; p=0.004).

In terms of device use, pacemakers were nearly twice as common among nonfrail participants (81.1 percent vs 43.8 percent), while ICDs (7.5 percent vs 33.3 percent) and CRTs (11.3 percent vs 22.9 percent) were more common options for frail patients.

Frail patients were also more likely to have been treated with β-blockers (27.7 percent vs 13.9 percent; p=0.001), mineralocorticoid receptor antagonists (15.8 percent vs 4.0 percent; p=0.002), diuretics (28.7 percent vs 9.9 percent; p<0.001), and amiodarone (14.9 percent vs 3.0 percent; p=0.001) than nonfrail comparators.

While the present findings point to a role of frailty in the postoperative course of CIED recipients, “the mFI is calculated based on items related to the patient’s medical history, meaning there is little room for improvement after surgery,” the researchers explained.

“This indicates the need for postoperative evaluations aimed at determining whether preoperative or postoperative frailty and cognitive dysfunction impact readmission,” they added.