Frailty helps predict adverse cardiac events after noncardiac surgery

Use of the validated Hospital Frailty Risk Score (HFRS) can help determine frail surgical inpatients who are susceptible to adverse perioperative cardiovascular outcomes, suggests a study.

“In this analysis of a large US database, nearly one-fifth of all patients undergoing noncardiac surgery had a combination of diagnoses indicative of at least moderate frailty defined by the HFRS,” the researchers said.

“Higher frailty scores were associated with increased risks of perioperative major adverse cardiovascular events (MACE), myocardial infarction, cardiac arrest, and all-cause mortality independent of age and other comorbidities,” they added.

The researchers identified 55,349,978 adults aged ≥45 years hospitalized for noncardiac surgery from 2004-2014 from the National Inpatient Sample. They used the validated HFRS derived from International Classification of Diseases codes to classify patients as low (HFRS <5), medium (HFRS 5‒10), or high (HFRS >10) frailty risk.

MACE, the primary outcome, was defined as myocardial infarction, cardiac arrest, and in-hospital mortality. The adjusted odds of MACE stratified by age and HFRS was estimated using multivariable logistic regression.

Of the hospitalizations, 81.0 percent had low HFRS, 14.4 percent had medium HFRS, and 4.6 percent had high HFRS. Patients with higher HFRS showed more cardiovascular risk factors as well as comorbidities. [Am J Med 2023;136:372-379.E5]

MACE occurred in 2.5 percent of surgical hospitalizations and more frequently among those with high frailty scores (high HFRS: 9.1 percent; medium: 6.9 percent; low: 1.3 percent; p<0.001).

MACE was also more likely to occur in patients with medium (adjusted odds ratio [aOR], 2.05, 95 percent confidence interval [CI], 2.02‒2.08) and high (aOR, 2.75, 95 percent CI, 2.70‒2.79) HFRS than those with a low frailty score, with the highest likelihood of MACE seen in younger individuals 45‒64 years of age (p<0.001 for interaction).

Frailty and age

“These findings suggest that frailty offers a unique measure of physiological capacity that is not captured by age alone,” the researchers said. “Although the comorbidity profiles of frail patients may differ with age, high frailty scores were associated with adverse events in all age groups.”

Previous studies also suggested that frailty could be a better predictor of adverse outcomes than age in patients undergoing noncardiac surgeries. [Circulation 2012;126:546-550; Interact Cardiovasc Thorac Surg 2014;18:580-585]

“Therefore, assessment of frailty is an emerging component of the preoperative evaluation for adults across the age spectrum, and based on this and other studies, the HFRS may serve as a valuable tool in addition to other frailty assessments for risk stratification, regardless of age,” the researchers said.

Traditionally, frailty referred to a state of functional decline from both ageing and disease-related changes over time. Earlier studies suggested that frailty may signify a chronic disease state related to systemic inflammation, which results in worsening morbidity among affected individuals. [Age Ageing 2019;48:388-394; Transplantation 2018;102:1740-1746]

In addition, elevated inflammatory markers common in frail patients are associated with the development of cardiovascular disease. [Ageing Res Rev 2016;31:1-8; Nat Rev Cardiol 2018;15:505-522]

Frail patients are also more likely to show nonadherence to their medications and have poor dietary habits as well as sedentary lifestyles. [Am J Geriatr Cardiol 2008;17:101-107; Clin Interv Aging 2016;11:1781-1790]

“Therefore, frailty may both directly contribute to and result from cardiovascular disease,” the researchers said.