Want to predict mortality in elderly TAVR, SAVR patients? Use this four-item scale

It’s logical that frailty factors into recovery from major heart surgery. But what, exactly, is the best method for judging a patient’s frailty before transcatheter or surgical aortic valve replacement (TAVR/SAVR)?

A study published online July 7 in the Journal of the American College of Cardiology explored this question by examining seven frailty scales in predicting poor outcomes.

“We sought to compare the incremental predictive value of frailty scales in a prospective multicenter cohort of older adults undergoing TAVR or SAVR,” wrote Jonathan Afilalo, MD, MSc, lead author from the division of cardiology at Jewish General Hospital in Montreal, Quebec, Canada, and colleagues. “Our overarching goal was to harmonize practice by providing clearer recommendations on how to best assess frailty, which would in turn be used to individualize care and improve outcomes in vulnerable patients.”

The cohort was assembled from 14 academic facilities in Canada, the United States and France. Patients need to be 70 years or older and undergoing SAVR or TAVR between 2012 and 2015. The cohort included 1,020 individuals with a median age of 82 years old—646 underwent TAVR and 374 underwent SAVR (195 with and 179 without concomitant coronary artery bypass). Each was given physical tests and questionnaires and then reevaluated at six and 12 months.

The following seven scales were used to measure frailty:

  1. The Fried scale: five items (gait speed, grip strength, weight loss, exhaustion and inactivity) with three needed for diagnosis.
  2. The Fried+ scale: The same items plus a cognition test and mood test with three needed for diagnosis.
  3. The Rockwood CFS scale: A score (from 1 to 9) from a semi-quantitative evaluation of the patient’s symptoms, mobility, inactivity, exhaustion and disability for daily living.
  4. The SPPB scale: Three physical tests (gait speed, time to stand five times and ability to stand with feet in tandem) with a composite score.
  5. The Bern scale: Six items (gait speed, cognition, nutrition, activities of daily living and instrumental activities of daily living) with a composite score.
  6. The Columbia scale: Four items (gait speed, grip strength, serum albumin and activities of daily living disability) with a composite score.
  7. The EFT scale: Four items (time to stand five times, cognition, hemoglobin and serum albumin) with a composite score.

After a year, 807 survived the procedure and completed the follow-up tests. Nearly 20 percent worsened by at least two deficits, while 80 percent improved or maintained deficits.

After adjustment, the EFT scale performed the best in associating death or worsening disability. The researchers noted, however, that measurements of frailty varied significantly depending on the scale, as did a score’s predictive power.

“The time and resources required to administer the EFT are minimal, and its components can be intervened upon before or after the procedure to optimize outcomes,” Afilalo et al. wrote. “Although EFT is not all-encompassing, it is a well-rooted starting point to test for frailty and to identify patients in whom further geriatric assessment should be considered.”

Of the six other scales, the Fried showed the least reliability to predict mortality both at 30 days and 12 months, followed by Fried+ and SPPB.