JoAnn Lindenfeld, MDProfessor of Medicine

Medical Director, Cardiac Transplant ProgramAssociate Director, Center for Women’s Health Research

University of Colorado

Frailty and Quality-Adjusted SurvivalMEDAMACS AND INTERMACS

• What is frailty and how is it measured?

• Why is frailty important in LVAD patients?

• What do we know about frailty in LVAD patients?

• What about INTERMACS and MEDAMACS?

Frailty and Quality-Adjusted SurvivalMEDAMACS AND INTERMACS

Frailty

Decline in physiological reserve

Impaired Resistance to stressors

Incomplete Recovery

Increased morbidity and mortality

Bergman H et al. J Gerontol A Biol S ci Med Sci 2007;62:731-7

Frailty is not always an “eyeball” impression

In fact frail patients are more likely to have a high BMI and central adiposity which masks “sarcopenia”

Afilalo J et al. JACC 2010;56L1668-76.Gallagher d AJP Endo 2000;297:E366-75Barzilay JL Arch Int MEd2007;167:635-41

There are a Number of Ways to Measure Frailty

• Frailty phenotype1

• Frailty index2

1 Fried LP et a. J Gerontol Collab Res Group 2001;56:146-52 Rockwood K et al. CMAJ 2005; 173:489-95

Fried Frailty Phenotype

Frailty Measure Criteria Scoring System

Validated Physical Performance Measures

Fried Criteria 1. Unintentional weight loss

2. Low grip strength

3. Self-reported exhaustion

4. Slow gait speed measured at

usual pace over 15 feet

5. Low self-reported physical

activity

0 criteria met: robust

or not frail

1-2 criteria met:

intermediate frail

≥ 3 criteria met: frail

Fried LP et al. J Gerontol A. Biol Sci Med 2001;56: M146-56; Banden-Roche K et al J Gerontol a Biol Sci Med Sci 2006;61:262-66;Xue Q-L et al. J Gerontol A. BiolSci Med Sci 2008; 63:984-990

A number of studies show that gait speed outperforms other criteria of frailty

INTERMACS and MEDAMACs15 foot gait speed

Instruct to “Walk at your comfortable pace” until a few steps past the 5-meter mark (should not start to slow down before)Begin each trial on the word “Go”Start the timer with the first footfall after the 0-meter lineStop the timer with the first footfall after the 5-meter lineFrailty is defined by the time to walk 15 feet*

Fifteen foot Gait Speed Test

Frailty Index

• A frailty index will be able to be constructed with a number of other “health deficits” already measured in INTERMACS and MEDACMACs

• These “health deficits” include co-morbidities captured in INTERMACS and may also include signs, symptoms, nutritional indices.

Rockwood K Mitinski A. BMC Geriatr 2008;8:24-34

Cumulative deficit index Cut-points1. Need help preparing meals Yes = 1, No = 02. Need help feeding yourself Yes = 1, No = 03. Need help dressing yourself Yes = 1, No = 04. Need help using the toilet Yes = 1, No = 05. Need help with housekeeping Yes = 1, No = 06. Need help climbing stairs Yes = 1, No = 07. Need help bathing Yes = 1, No = 08. Need help walking Yes = 1, No = 09. Need help using transportation Yes = 1, No = 010. Need help getting in and out of bed Yes = 1, No = 011. Need help managing medications Yes = 1, No = 012. Depend on assistive devices (walker, cane, etc.) or other people to perform activities of daily life

Yes = 1, No = 0

13. Dependent on a device for normal breathing Yes = 1, No = 0

14. Climb 2 flights of stairs without rest No, cannot do at all = 1; Yes, with difficulty = 0.5; Yes with no difficulty = 0

15. Myocardial infarction Yes = 1, No = 016. Diabetes Yes = 1, No = 017. Peripheral vascular disease Yes = 1, No = 018. Cerebrovascular disease Yes = 1, No = 019. Chronic obstructive pulmonary disease Yes = 1, No = 020. Ulcer Yes = 1, No = 021. Hemiplegia Yes = 1, No = 022. Moderate/severe renal insufficiency Yes = 1, No = 023. History of liver disease Yes = 1, No = 024. Rheumatologic disease Yes = 1, No = 025. History of malignancy Yes = 1, No = 026. History of dementia Yes = 1, No = 027. Hypertension Yes = 1, No = 028. Hyperlipidemia Yes = 1, No = 0

29. Body mass index Underweight or obese = 1; overweight = 0.5; normal = 0

30. Depression Yes = 1, No = 031. Anemia Yes = 1, No = 0

Frailty(Deficit) Index Predicts Mortality and Rehospitalizations

Dunlay SM et al. J HLTx 2014;33:359-65

Mortality and Rehospitalization

(0.32 = frail, 0.23 to 0.32 = intermediate frail, <0.23 = not frail).

1 2 3 4 5 6-10

0

10

20

30

40

50

60

70

80DominantNon-Dominant

**

* **

* p <0.05** p <0.005

Months After LVAD Placement

% C

ha

ng

e in

HG

S/B

W

Chung CJ et al. J Card Failure 2014;20:310-15

Frailty (Handgrip) Predicts Mortality and Improves post LVAD

n = 72

n = 31

n = 26

INTERMACS AND MEDAMACS Both Frailty Phenotype and Frailty Index

are Available

• Frailty phenotype = Gait speed

• Frailty index = Can come up with multiple indices based on demographics, comorbidities, and labs

MEDAMACS Baseline A and Baseline B (n = 53)

Characteristic Baseline A Baseline B

Gait Speed (M/sec) N=36 N=31

mean 1.0 (0.5) 1.1(0.4)

median 1.0(.7-1.2) 1.1(0.9-1.4)

6 minute walk

Mean(SD) 264.3(129) 248.1(127.8)

Median(IQR) 280(182.9-321.3) 274.9(130.1-337.7)

INTERMACS AND MEDAMACS Both Frailty Phenotype and Frailty Index are Available

• How closely does gait speed (frailty phenotype) correlate with frailty indices?

• Does heart failure alone cause frailty?• Is frailty predictive of heart failure progression?• Do either frailty phenotype or index predict

irreversibility of frailty?• What outcomes do the frailty phenotype and indices

predict—are they different? (eg respiratory failure, recovery to home)

• How closely does frailty correlate with quality of life?