Frailty Linked to Lower Use of Guideline Treatments in HFrEF

Frailty Linked to Lower Use of Guideline Treatments in HFrEF


Physical frailty is significantly associated with reduced prescribing of guideline-recommended drugs in heart failure patients with reduced ejection fraction.


  • The multicenter observational study included 1041 patients with acute heart failure with reduced ejection fraction (HfrEF) (mean age, 72 years); 71% were men.

  • Researchers created a prognostic score of physical frailty based on grip strength, walking speed, and other factors. They grouped patients into increasingly severe categories of frailty: I, ≤3 points; II, 4–8 points; III, 9–12 points; and IV, 14 points. (A score of 13 did not exist in the calculation.)

  • They gathered information on prescription rates of guideline-recommended therapies, including angiotensin-converting enzyme inhibitors (ACEIs)/angiotensin receptor blockers (ARBs), β-blockers, and mineralocorticoid receptor antagonists (MRAs).

  • The primary outcome was all-cause death or first HF rehospitalization up to 2 years from discharge.


  • Severity of physical frailty was an independent predictor for nonuse of ACEs/ARBs (odds ratio [OR], 1.23 per 1 category increase) and β-blockers (OR, 1.32), but not MRAs.

  • The proportion of patients who received triple therapy decreased as physical frailty increased (P for trend, <.001), with about half the rate in the frailest patients (23.4%) compared with the least frail patients (40.2%).

  • Physical frailty remained an independent predictor of low prescription rates after adjusting for more advanced age and comorbidity.

  • Patients who used fewer drugs had a worse prognosis in terms of all-cause death or HF hospitalization, regardless of severity of physical frailty.


An effective strategy to improve medical therapy, accounting for physical frailty, is urgently needed, said the authors.


The study was carried out by Toru Kondo, MD, PhD, Department of Cardiology, Nagoya University Graduate School of Medicine, Nagoya, Japan, and colleagues. It was published online June 10, in the Journal of the American Heart Association.


The study was observational, did not have data on whether clinicians considered if a drug was contraindicated, was conducted before the approval of sacubitril/valsartan and sodium-glucose cotransporter-2 inhibitors in Japan, and did not include an analysis of drug doses.


The study is supported by the Japan Society for the Promotion of Science. Kondo receives grants from the Uehara Memorial Foundation and the Japanese Heart Failure Society. Author John J. V. McMurray, MD, is supported by the British Heart Foundation Centre of Research Excellence.

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