ESC HEART FAILURE ORIGINAL ARTICLE

ESC Heart Failure 2022; 9: 4053–4063

Published online 30 August 2022 in Wiley Online Library (wileyonlinelibrary.com) DOI: 10.1002/ehf2.14040

Practical management of frailty in older patients with

heart failure

Statement from a panel of multidisciplinary experts on

behalf the Heart Failure Working Group of the French
Society of Cardiology and on behalf French Society of
Geriatrics and Gerontology

Anne-Sophie Boureau1*, Cédric Annweiler2, Joël Belmin3, Claire Bouleti4, Mathieu Chacornac5,
Michel Chuzeville6, Jean-Philippe David7, Patrick Jourdain8, Pierre Krolak-Salmon9, Nicolas Lamblin10,
Marc Paccalin11, Laurent Sebbag12 and Olivier Hanon13
1
Department of Geriatrics, University Hospital, Nantes, France; Institut du Thorax, University Hospital, Nantes, France; 2Department of Geriatric Medicine and Memory
Clinic, Research Center on Autonomy and Longevity, University Hospital, Angers; UPRES EA 4638, University of Angers; Gérontopôle Autonomie Longévité des Pays de la
Loire; Robarts Research Institute, Department of Medical Biophysics, Schulich School of Medicine and Dentistry, University of Western Ontario, London, ON, Canada; 3Hôpital
Charles Foix et Sorbonne Université, Ivry-sur-Seine, France; 4Cardiology, University of Poitiers, Clinical Investigation Center (CIC) INSERM 1402, Poitiers University Hospital,
Poitiers, France; 5Department of Cardiology, Annecy Genevois Hospital, Annecy, France; 6Geriatric Cardiology Department, Edouard Herriot Hospital, Hospices Civils de Lyon,
Lyon, France; 7INSERM- U955, IMRB, CEpiA team, Department of Geriatric Medicine, AP-HP, Hôpitaux Henri-Mondor, Univ Paris Est Creteil, Creteil, France; 8DMU COREVE,
GHU Paris Saclay, APHP, Paris, France; INSERM UMR S 999, IHU TORINO (thorax Innovation), Turin, Italy; 9Clinical and Research Memory Center of Lyon, Lyon Institute For
Elderly, Hospices Civils de Lyon, Villeurbanne, France; University of Lyon, Lyon, France; Neuroscience Research Centre of Lyon, INSERM 1048, CNRS, Lyon, France; 10Institut
Cœur Poumon, CHU de Lille, Inserm U1167, Institut Pasteur de Lille, Université de Lille, Lille, France; 11Department of Geriatrics, CHU La Milétrie, CIC-1402, Poitiers, France;
12
Service Insuffisance Cardiaque et Transplantation Hospices Civils de Lyon Hôpital Louis Pradel, Bron, France; and 13Department of Geriatrics, Université de Paris, EA 4468,
APHP, Hôpital Broca, Paris, France

Abstract
Aims The heart failure (HF) prognosis in older patients remains poor with a high 5-years mortality rate more frequently
attributed to noncardiovascular causes. The complex interplay between frailty and heart failure contribute to poor health
outcomes of older adults with HF independently of ejection fraction. The aim of this position paper is to propose a practical
management of frailty in older patients with heart failure.
Methods A panel of multidisciplinary experts on behalf the Heart Failure Working Group of the French Society of Cardiology
and on behalf French Society of Geriatrics and Gerontology conducted a systematic literature search on the interlink between
frailty and HF, met to propose an early frailty screening by non-geriatricians and to propose ways to implement management
plan of frailty. Statements were agreed by expert consensus.
Results Clinically relevant aspects of interlink between frailty and HF have been reported to identify the population eligible
for screening and the most suitable screening test(s). The frailty screening program proposed focuses on frailty model defined
by an accumulation of deficits including geriatric syndromes, comorbidities, for older patients with HF in different settings of
care. The management plan of frailty includes optimization of HF pharmacological treatments and non-surgical device
treatment as well as optimization of a global patient-centred biopsychosocial blended collaborative care pathway.
Conclusion The current manuscript provides practical recommendations on how to screen and optimize frailty management
in older patients with heart failure.

© 2022 The Authors. ESC Heart Failure published by John Wiley & Sons Ltd on behalf of European Society of Cardiology.
This is an open access article under the terms of the Creative Commons Attribution-NonCommercial-NoDerivs License, which permits use and distribution in any medium,
provided the original work is properly cited, the use is non-commercial and no modifications or adaptations are made.
4054 A.-S. Boureau et al.

Keywords Heart failure; Frailty; Older patients; Practical management

Received: 4 January 2022; Revised: 2 May 2022; Accepted: 9 June 2022
*Correspondence to: Anne-Sophie Boureau, Department of Geriatrics, University Hospital, 44093 Nantes, France. Tel: +33 2-40-16-50-46.
Email: annesophie.boureau@chu-nantes.fr

Introduction frailty screening by non-geriatricians and a management

plan of frailty in HF patients.
Heart Failure (HF) prevalence increases with age, doubling
from 6% of general population aged 60 to 79 years to
approximately 12% above >80 years.1 The high prevalence Frailty in heart failure patients
of HF likely relates to numerous of HF risk factors, such as
coronary artery disease and hypertension, increasing with Prevalence and prognostic impact of frailty in
age. The HF prognosis in older patients remains poor with a
heart failure patients
high 5 years mortality rate (54.4%), more frequently attributed
to non-cardiovascular causes (54.3%).1 The complex interplay
In community-dwelling adults aged 65 and older, the frailty
of frailty, co-morbidities, cognitive and physical function, and
prevalence is between 3% and 23%.3,7 Even though there is a
social context contribute to poor health outcomes of older
considerable frailty prevalence heterogeneity between stud-
adults with HF independently of ejection fraction. The role
ies due to different frailty measures (different tools, validated
and goals of care of each of these factors are uniquely relevant
or adapted) and study settings, the frailty prevalence in HF pa-
to the implementation and success of HF management.
tients is still high.8 For instance, a survey of 1727 community-
The concept of frailty and its different approaches describe
dwelling HF older patients found a prevalence of frailty as in
a dynamic and intermediate state prior to disability, charac-
Rockwood approach, up to 94% of subjects.9 In another study
terized by diminished capacity to respond to stressors due
using multiple frailty screening tools in 487 community-
to a reduced functional reserve. Even though there is no
dwelling older patients, the prevalence of frailty was between
single standard definition, this key concept of frailty and its
30% and 52% for chronic HF patients.10 For hospitalized HF
different approaches are associated with poor outcomes such
patients, the frailty prevalence varies between 56 and 76%,
as: falls, morbidity, disability, polypharmacy, hospitalization,
independently of left ventricular ejection function.11,12 In the
institutionalization and mortality.2 The two main approaches
specific setting of heart failure patient candidate for left ven-
of frailty are (i) a physical phenotype approach proposed by
tricular assist device, the frailty incidence as reported in the
Fried and colleagues in 2001, based on five directly or
meta-analysis of Tse et al was as high as 21% of the population
self-reported measures of weight loss, exhaustion, slow gait
despite the relative young age (57.7 ± 15.3 years old).13
speed, weak handgrip strength, and low physical activity3;
Despite the lack of standardization of frailty definition and
(ii) alternatively, a frailty approach proposed by Rockwood
measures (Fried criteria, Rockwood criteria, etc.), previous
and colleagues based on an accumulation of deficits including
studies report strong association between frailty and a higher
geriatric syndromes, co-morbidities as cognitive status or car-
risk of death, hospitalizations, and functional decline for HF
diovascular diseases reducing functional reserve.4 The two
patients9,14–23 (Table 1).
models of frailty recognize subjects at different time of re-
duced functional reserve which generate different clinical
and prognosis implications. Indeed, Fried frailty phenotype Interlink between frailty and heart failure
identifies subjects at the initiation of reduced function re-
serve, with an increased risk of potential negative outcomes Interlink between HF and frailty are tenuous. On one hand,
in presence of stressors, and mortality at 2 years around chronic HF undeniably induces frailty. HF is one of the major
10%.3,5 Rockwood model as a deficit accumulation model, co-morbidities taken into account in frailty models as in
identifies patients with already diagnosed diseases including Rockwood’s.4 This disease also induces fatigue, decrease in
falls and cognitive impairment. Patients with high Rockwood muscle strength, and sometimes decrease in physical activi-
frailty score have a high 2 years mortality rate, more similar ties. All these factors are included in Fried’s frailty model.3
to the one observed in patients with severe disability.2,6 In addition, chronic HF (CHF) can increase or even initiate
Because of the complex and multifaceted nature of frailty, a cognitive disorder by inducing major executive
understanding its relationship with HF and its management impairments.24 This interaction explains the impact of CHF
is important for optimal global care and treatment. The aim on frailty, regardless the frailty definition. On the other hand,
of this position paper proposed by an expert panel composed frail patients have a diminished capacity to respond to
of HF specialist/cardiologist and geriatrician, is to explore stressors as acute HF. Indeed, their maximum functional ca-
the interlink between frailty and HF, to propose an early pacity decreases below the level required under stressful

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 Frailty and heart failure

Table 1 Published studies on frailty impact on prognosis in heart failure (HF) patients, from latest meta-analysis (2018) until May 2021

Study Characteristics of the Time to

Authors Study population N study population Outcomes follow up HR or OR (95% CI) P-value
16
Zheng et al. 2021 Prospective Inpatients with 443 Mean age: 76.1 Composite: 6 months follow up HR = 1.78 (1.02–3.10)
cohort study acute HF 50.8% male Mortality and P = 0.041
readmission
17
Weng et al. 2021 Retrospective Older inpatients 811 Mean age of HF Mortality Median follow up HR = 1.05 (1.0004–1.10)
cohort study in Geriatric patients = 82.7 3.2 years P < 0.05
department 73.5% male
19
Kohsaka et al. 2020 Retrospective Veterans with HF 163 085 Mean age of frail Composite: 2 years OR = 1.71, (1.65–1.77)
cohort study patients = 77 Mortality and
97.2% male readmission
18
Matsue et al. 2020 Prospective Inpatients with 1180 Mean age = 81 Composite: 1 year HR = 2.04 (1.28–3.24)
cohort study acute HF 57.4% male Mortality and P = 0.003
readmission
20
Dewan et al. 2020 Prospective HF-rEF 13 265 Mean age = 65 Composite: 26.6 months HR = 1.71 (1.56–1.88)
study (PARADIGM) 22.2% female Mortality and P < 0.001
readmission
15
Kwok et al. 2020 Retrospective Inpatients with 11 626 400 In-hospital OR = 3,05 (2,57-3,62)
cohort study acute HF mortality P < 0,001
21
Newton et al. 2019 Prospective Inpatients with 811 Mean age = 77 Mortality 1 year HR = 1.98 (1.18–3.30)
cohort study acute HF P < 0.01
22
McAlister et al. 2019 Retrospective Inpatients with 26 626 Mean age = 77.4 Mortality 30 day and 90 days P < 0.01
cohort study acute HF
23
Bottle et al. 2019 Retrospective Primary care 6360 82% > 65 years First admission 1 year HR = 2.57 (1.69–3.90)
cohort study 44.5% female P < 0.001
14
Yang et al. 2018 Meta-analysis Inpatients with 2645 Mortality Median follow-up: HR = 1.54 (1.34–1.75)
acute HF 1.8 years P < 0.001

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4056 A.-S. Boureau et al.

Figure 1 (A) Schematic mechanisms of frailty in aging. Maximum functional capacity (blue line) decreases with age, as well as functional reserve.
Frailty occurs when maximum functional capacity decreases below the level required under stressful conditions (arrow 2). In young individuals, func-
tional capacity is sufficient to overcome stressful conditions. The slope of functional decline varies among individuals. Persons with slower decline ex-
perience successful aging and are not frail (green line, arrow 3) and those with steeper decline experience accelerated aging and greater frailty (red line
and arrow 1). (B) Heart failure (HF) may alter functional capacity through a decrease functional reserve and an increase frailty (arrows 4 and 5). The
effects of acute HF on frailty might be reversible after recovery.

conditions. However, the effects of acute disease might be re- Practical guide to screen for frailty in
versible after recovery (Figure 1).
Given the close interlink between HF and frailty, it seems heart failure patients
essential to screen for frailty in older HF patients and vice
versa to optimize HF treatment in older patients to avoid A screening programme is not just a single test but rather a
an acute decompensation, a major stressor which can pathway that starts by identifying the population eligible for
accelerate functional impairment toward major disability. screening and stops when interventions, treatment and out-
Furthermore, beneficial treatment interventions can be im- comes are reported1 (Figure 2, and Table 2 and 3). The expert
plemented to reduce impact of frailty.25 panel, on behalf the Heart Failure Working Group of the
French Society of Cardiology and on behalf French Society
of Geriatrics and Gerontology, focused on the frailty model
Benefits of frailty management based on an accumulation of deficits including geriatric syn-
dromes, co-morbidities as cognitive status or cardiovascular
Patients with both frailty and CHF require an individualized diseases reducing functional reserve.
management approach. Whatever the frailty definition used
(Fried or Rockwood model), the implementation of treatment
should include a multidisciplinary approach with pharmaco-
logical and non-pharmaceutical treatment as psychological Who?
and social care.
In 1995, MW Rich et al., reported in a randomized prospec- Regarding the high prevalence of frailty in older patients with
tive study the value of coordinated multidisciplinary interven- HF, regardless of left ventricular ejection fraction, acute or
tion to increase quality of life, and to reduce 90 days-read- chronic HF, its screening and management should therefore
mission, total medical cost and mortality of HF older be a priority for the HF teams. Because frailty prevalence in-
patients.26 Although this study did not include frailty tools, creases with age, with or without co-morbidities, the patient
the multidisciplinary care plan corresponded to what can be we would select as a particular target for frailty screening
proposed for this disease. Since then, other interventional would be a patient with HF aged 75 and older.32,33 It does
studies with implementation of specific frailty management not seem appropriate to restrict the target population ac-
have been published. The value of physical activity alone re- cording to co-morbidities because frailty may be secondary
mains debated. Thus Chen’s meta-analysis (which included to heart failure itself. Indeed, frailty if cardiac surgery, surgi-
7 randomized trials) showed a positive effect of physical ac- cal, and non-surgical device treatment is considered, the
tivity on the 6-minute walking test and quality of life but no frailty screening should be proposed for patients aged
impact on hospitalization or mortality.27 However, a random- >65 years or sometimes even youngers.13 It is nevertheless
ized study confirmed the benefit of a combined intervention proposed to avoid screening for frailty in patients with pallia-
(dietary advice, psychological support, locomotor rehabilita- tive care whether for a terminal HF or for other reasons as
tion) with specialized follow-up to optimize management of completely dependent patients, approaching the end of life,
frail HF patients compared with standard management.28 who could not recover even from a minor illness.

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Frailty and heart failure 4057

Figure 2 Collaborative care for older patients with HF.

When? depending on the local and logistical resources. The screening

tools can be carried out by the hospital cardiology team ideally
HF has two very distinct clinical presentations: outpatients specialized in HF, the resident or medical student, or a nurse.35
with chronic HF and inpatients with acute HF. In each situa- Outpatient frailty screening test can be carried out by general
tion, screening for frailty is necessary as it is associated with practitioners, referred cardiologists, advanced practice nurses
poor outcomes for both inpatients and outpatients.14,19,23 Un- or nurses for patient education, at any time during the usual
stable HF leads to frequent readmission each time associated follow-up for HF.36,37
with an increase of frailty.34 The tool used for frailty screening
in inpatients or outpatients might vary due to the healthcare
settings and inpatients capacities. In order to have one simple How?
message, the expert panel wanted to select one simple screen-
ing tool that could be used in different settings. Therefore, be- The frailty defined by an accumulation of deficits including ge-
side acceptable test performance in different settings of care, riatric syndromes and co-morbidities, can be assessed by a
the screening tool should be feasible and with a good patient’s multidimensional comprehensive geriatric assessment. This
acceptability in these different settings. Frailty screening tools is neither feasible nor likely to be relevant for frailty assess-
must not take more than few minutes to complete.10 For inpa- ment in all older HF patients. Among the instruments available
tients, the screening test will therefore preferably be carried and validated for frailty assessment in older subjects, the most
out in the cardiology department or in cardiac intensive care commonly used are the one used for the different approaches:
unit once the diagnosis of HF has been confirmed and the Fried criteria3 and the Rockwood Clinical Frailty Scale.4 How-
prognosis evaluated. Moreover, screening must be carried ever, these tools are time-consuming to perform or requires
out early, ideally within the first 48 hours, in order to propose specific equipment (dynamometer for Fried Criteria). In order
an individualized care plan during and after the hospital stay, to facilitate implementation in daily practice, it is necessary to

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4058 A.-S. Boureau et al.

Table 2 Details and predictive values of frailty screening tools: TRST, SEGA-A, and VES-13

SEGA A VES-13 TRST

Type of instrument Patient assessment Questionnaire for patients Patient assessment
or caregivers (face-to-face
or telephone interview)
Duration (min) 10 3–5 1–5
Number of items 13 13 5
Type of items Age Age History or evidence of
Drugs Self-perception of health cognitive impairment
Mood Difficulties for 6 physical Recent hospitalization or
Self-perception of health activities emergency visit
Falls Limitation for 5 activities of Gait disturbances or falls
Nutritional status daily living due to health Use of 5 drugs or more
Co-morbidities problems Independence for activities
Incontinence of daily living performed by
Need of help for daily living a nurse, elder abuse,
activities substance abuse,
Cognitive function medication non-compliance
Items Scoring and Scale Threshold Three-level Two to three-level Two-level
Threshold > 8 Threshold ≥ 3 Threshold ≥ 2
Context of care of validation Emergency, hospitalization Community dwelling elders Emergency, hospitalization
in primary care,
hospitalization, surgery and
cancer patients, emergency,
inpatients of cardiology
ward*
Predictive values (Se, Spe) for
45 42
Mortality Yes Yes (Se: 87%, Sp: 47%) Yes
42
Institutionalization Yes Yes (Se: 92%, Sp: 50%) No
48
Hospitalization Yes No Yes (Se: 83%, Sp: 32%)
42 48
Functional decline Yes Yes (Se: 91%, Sp: 59%) Yes (Se: 66%, Sp: 47%)
Strengths Multiple predictive Validated in numerous Simple 5 questions
outcomes different settings Short screening tool
Rapid screening tool
Limitations Require a longer time to Sensitivity and specificity Sensitivity and specificity
complete are unknown to predict risk are unknown to predict risk
of hospitalization of institutionalization
TRST, Triage Risk Screening Tool; SEGA, Short Emergency Geriatric Assessment); VES13, Vulnerable Elders Survey-13; Se, Sensitivity; Spe,
Specificity.

use simplest screening tools instead of assessment tools, inte- incorporating elements of the geriatric assessment can be
grated in a pre-established care pathway. Numerous frailty used. The HFA of ESC has proposed a HF-specific tool based
screening tools have been developed in general population on four major domains (clinical, psycho-cognitive, functional,
as Clinical Frailty Scale, Frailty Phenotype, SHARE-FI, FRAIL, … and social).39 For the moment, domains have been defined
as well as tools in order to identify older adults who may ben- but agreement on the specific items to include in these four
efit from a geriatric assessment as Short Emergency Geriatric domains is needed, as well as the validation (specific and sen-
Assessment (SEGA), Vulnerable Elders Survey-13 (VES-13) or sitive) of this new score in identifying patients with frailty in HF
Triage Risk Screening Tool (TRST)1 (tools are in the supporting cohort studies.39 Others tools including domains of the geriat-
information).10,35,38 ric assessment already exist.
In a systematic review published in 2018 with 20 studies, The Vulnerable Elders Survey-13 (VES-13) is a 13-item
Mc Donagh J. et al analysed 8 frailty screening tools and frailty questionnaire developed through analysis of nationally repre-
assessment tools in HF patients. Even though frailty is an im- sentative sample survey data of older patients in the United
portant prognostic indicator in HF patients and needs a holistic States in 2001.40 This scale can be easily administered during
therapeutic approach, screening tools are not fully validated in a face-to-face or telephone interview in a few minutes by cli-
these patients.35 In another study with ambulatory HF nicians or non-clinicians. It has been assessed in outpatient
patients, Clinical Frailty Scale (CSF) has a high correlation with and inpatient care and is applicable in primary care.41,42
assessment tools and the lowest misclassification rate in iden- The Short Emergency Geriatric Assessment (SEGA-A) was
tifying frailty according to the standard combined frailty proposed in 2004 for an early geriatric syndrome identifica-
index.10 Further studies are needed to clarify if these simple tion in emergency ward.43,44 The SEGA tool has been vali-
frailty screening tools have comparable prognostic value to dated with general practitioners.45 This screening has the
more comprehensive frailty assessments for HF patients. In or- advantage of being largely validated (in emergency wards,
der to identify the main factors of frailty from the outset, tools in hospital and outpatient departments) because it has very

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Frailty and heart failure 4059

Table 3 Primary prevention of frailty and optimization care of geriatric syndromes in elderly HF subjects angiotensin-converting enzyme
inhibitors (ACE-I), angiotensin receptor blockers (ARBs) and angiotensin receptor neprilysin inhibitors (ARNIs) together with
mineralocorticoid receptor antagonists (MRAs), sodium-glucose co-transporter 2 inhibitors (SGLT2i), beta-blockers (BB)

Prevention Treatment
29
HFrEF • Treatment of risk factors as cardiovascular chronic • Optimal therapy (ACEi or ARNI, BB, MRA, SGLT2i)
diseases: hypertension, diabetes, atrial fibrillation • Refer to resynchronization if indicated
HFpEF • Optimal diuretic management adapted to co-morbidities
therapeutics
• Exercise training programme, 2–3 times/week
Co-morbidities and • Treatment doses management according to renal • Check co-morbidities management including iron
polypharmacy clearance deficiency
30
• Try to use a single drug to treat two or more diseases • Priority setting for patients with multiple co-morbidities
• Patient and caregiver information about each • Medication review
medication

Sarcopenia • Regular physical exercise adapted to patient capacity • Exercise training programme, which includes aerobic,
strength, and balance exercises, 2–3 times/week
• Combination of nutrition and exercise programmes
Malnutrition • Weight monitoring • Energy input of 30 to 40 kcal/kg/day
• Protein intake: 1 to 1.2 g/kg/day • Protein intake: 1.2 to 1.5 g/kg/day
• Regular physical exercise adapted to patient capacity • +/ oral nutritional supplements
• Regular physical exercise adapted to patient capacity
Physical function • Screen for orthostatic hypotension • Identify and treat risk factors including psychotropic drugs
and falls • Sufficient water supply reduction
• Regular physical exercise adapted to patient capacity • Search for potential precipitating risk factors
31
• Vitamin D supplementation
• Environmental assessment
• Exercise training programme, which includes aerobic,
strength, balance and flexibility exercises, 2–3 times/week
Depression • Combatting Social Isolation • Medication if needed: selective serotonin reuptake
inhibitors
• Psychotherapy
Cognitive impairment • Treatment of chronic diseases such as hypertension or • Specific attention to drug adherence (home help to deliver
atrial fibrillation to prevent cognitive decline. treatments)
• Social participation • Specific treatments and social support
• Cognitive stimulation
Vaccination • Influenza, pneumococcal, SARS-CoV2

Social • Therapeutic compliance screening • Social support

• Nurses for treatment

good feasibility and acceptability, reproducibility and very After screening?

good test performances. It takes 5 min to complete by profes-
sionals who are not necessarily doctors and who may be from After positive screening, integrated care pathways between
the medico-social field.45 cardiologists and geriatricians should be clear for HF patients
The Triage Risk Screening Tool (TRST) is a screening tool and all practitioners involved. Indeed, the final aim of this
validated in 2003 in two emergency departments in screening is to propose a multidimensional global
Cleveland.46 It predicts a high risk of readmission and cardiogeriatric assessment and to initiate the multidimen-
adverse events. It can be performed in a few minutes by a sional care plan for patients with positive screening tools.
non-physician. As SEGA-A and VES-13 tools, TRST tool has For patients with normal screening tools, the interval for
the advantage of exploring all the elements of the geriatric re-evaluation can be of 1 year.
assessment and thereby identifying the main factors of frailty
from the outset. In 2013 in France, the French Health
Authority (Haute Autorité de Santé, HAS) published
recommendation on ‘How to reduce avoidable readmission Practical guide for frailty management
of older patients?’ in which this tool was proposed in order in older patients with heart failure
to implement a geriatric follow up after hospitalization.47
The predictive value of these scales in determining older The aim of geriatric and cardiologic collaboration in inte-
patients at increased risk of functional decline, institutionali- grated care pathways is to reduce mortality, hospitalizations
zation, or death are summarize in Table 2. and readmission for HF, to improve the quality of life and

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4060 A.-S. Boureau et al.

functional status of frail HF patients. The goal of the team is ment, especially for HFpEF patients, is also challenging
also to achieve patient preferences in the patient’s treatment particularly to prevent complications such as cardio-renal
plan including pharmacological treatment optimization and syndrome.
global care plan optimization.49,50 In all cases, co-morbidities treatment should be also
optimized as these co-morbidities can lead to HF decompen-
sation and increase frailty. Iron deficiency and Vitamin D
Optimizing pharmacological treatments and deficiency should be investigated as it is recommended to
non-surgical device treatment correct deficiencies by injectable iron in HFrEF patients, and
oral D Vitamin deficiency in older patients.29,31 Finally, influ-
HF treatment is based on the European Society of Cardiology enza, pneumococcal, and SARS-CoV-2 vaccinations are also
Guidelines for the diagnosis and treatment of acute and essential in this targeted population.
chronic HF.29 First, it is essential that older patients have at
least one cardiologic evaluation with an echocardiography if
practitioner suspects HF diagnosis. Transthoracic echocardi- Optimizing global patient-centred
ography is the method of choice for assessment of myocar- biopsychosocial blended collaborative care
dial systolic and diastolic function and to search for a differ- pathway
ential diagnosis with its own management (valvular disease
and cardiac amyloidosis). In geriatric wards, nearly 50% of Non-pharmacological treatment is essential for older patients
older HF patients do not have at least one echocardiography with HF. The limited evidence supporting the effectiveness of
or a known left ejection ventricular function (LVEF).51 Differ- exercise tailored to older and frail HF patients highlights the
entiation of patients with HF based on LVEF is important due current gaps in their management. In HF patients including
to different underlying aetiologies, co-morbidities and re- patients with preserved ejection fraction, endurance exer-
sponse to treatment (ESC Guidelines). Secondly, recom- cise, such as cycling or walking, can improve exercise
mended therapies for HFrEF improve functional capacity, capacity.61 Indeed, 2021 ESC guidelines recommends a super-
reduce mortality and acute hospital admission. Initiating vised, exercise-based, cardiac rehabilitation programme for
treatment and/or drugs doses titration [ACE inhibitors, frail patients with HF.29 Aerobic exercise combined with resis-
beta-blockers, angiotensin receptor blockers (ARBs), mineral- tance training appears to be effective in preventing muscle
ocorticoid receptor antagonists (MRAs) and angiotensin re- loss associated with HF. For older patients, a multicomponent
ceptor neprilysin inhibitor (ARNI), sodium-glucose co-trans- exercise training programme, which includes aerobic,
porter-2 inhibitors (SGLT2is)] can be challenging in frail strength, and balance exercises, is considered to be the most
older patients due to several reasons: the risk of side effects effective for improving mobility and gait, increasing muscle
is increased by co-morbidities (e.g. renal insufficiency), mass and strength, decreasing falls, enhancing functional per-
polypharmac,y and drug interactions, the expected benefit formance of activities of daily living, and improving quality of
of these therapies and their time to action is more complex life.62 The use of exercise games might be a way to encourage
to evaluate because frail older patients are often excluded patients with HF to exercise especially those who may be re-
from original studies.52 Thus, the benefit–risk balance is luctant to more traditional forms of exercise.63 In this con-
sometimes difficult to assess. Tools exist to help clinician to text, these types of exercises could be proposed to older HF
review appropriate or potentially inappropriate medication patients. Furthermore, it is widely acknowledged that a
in older adults, such as the STOPP and START tool.30 How- combination of nutrition and exercise programmes is one
ever, randomized trials conducted in patients with reduced valuable approach to the management of the physical com-
ejection fraction HF and large observational studies have ponents of frailty. And insufficient calorie intake is associated
shown a beneficial effect of these drugs, regardless of with poorer post-discharge quality of life and increased bur-
age.53–58 Recently, an expert consensus from French Society den of readmission in patients with HF.64 The shift of dietary
of Geriatrics and Gerontology emphasizes that the manage- strategy to frailty prevention with advancing aging in combi-
ment of HF in the very old patient can still be improved by nation with exercise, could improve quality of life in older
optimizing HF drugs especially in HF with reduced ejection adults with HF.65 This include dietary advice, fortified diet
fraction (HFrEF).59 Given that undertreatment and medica- and oral protein-energy supplementation if needed.
tion deprescribing of recommended treatments can lead to In the same time, identification of geriatric syndromes is
a worsening of HF, therapeutic optimization between general needed in order to optimize geriatric care plan.66 The
practitioner (GP), cardiologists, and geriatricians is therefore multimodal geriatric care plan is based on the treatment of
essential. Similarly, non-surgical device treatment as cardiac sarcopenia, malnutrition, impaired physical performance,
resynchronization therapy can improve the prognosis and depression, cognitive impairment and finally social care if
quality of life of older patients with HFrEF but their benefit necessary. For each component, a first step treatment is
may be lessened in frail patients.60 Finally, diuretic manage- detailed in Table 2. These approach are complementary and

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DOI: 10.1002/ehf2.14040
Frailty and heart failure 4061

often interlinked, and therefore require an integrated and from the outset seems to be more suitable for a first step of
patient-centred care plan. global care management. Beneficial treatment interventions
Furthermore, even if HF patients are not frail, its preven- can be implemented to reduce impact of frailty and improve
tion is necessary regarding the interlink between the two heart failure outcomes. Optimizing the care of older adults
diseases. The proposed prevention interventions in order to with HF is challenging and needs new specific pathways.
preserve functional status are detailed in Table 3. Frail older patients with HF would benefit from common
The integrated care pathway will depend of the initial cardio-geriatric recommendations.
screening circumstances. First of all, the implementation of
screening for frailty will be more efficient if practitioners
are aware of these diseases’ impact and their interlink with Acknowledgements
HF. After the screening step, several actions will be proposed
in order to optimize geriatric and cardiologic care as shown in The authors acknowledge technical support from Novartis for
Figure 2. For complex cases, a complete geriatric assessment illustrations and for the financial support from Gérontopôle
and a multidisciplinary discussion involving cardiologist and d’Ile de France (Gérond’if) for the publication fees. Novartis
geriatrician will be needed to define care plan priorities.50,67 and Gérond’if provided financial support for logistic manage-
New cardiogeriatric integrated care models are needed. ment and was not involved in the writing of the manuscript.
Given the prevalence of co-morbidities and geriatric syn-
dromes, one can imagine follow-up in a cardiogeriatric day
hospital in order to reduce number of patient’s visits and to Conflict of interest
give specialized HF and frailty care plan. Another care
plan could be developed for outpatients with advanced O.H. received personal fees from Novartis, Bayer, Servier,
practice nurses, nurses for patient education or nurse-led Pfizer, BMS, Boehringer Ingelheim, Astra Zeneca, Vifor, Leo
programmes, telemedicine, telerehabiliation platform.68,69 pharma, Sanofi, Medtronic. The rest of the authors have
nothing to disclose.

Conclusions
Supporting information
Given the strong association between frailty, heart failure and
morbi-mortality, it seems essential to screen for frailty in Additional supporting information may be found online in the
patients with HF. Among the numerous frailty screening Supporting Information section at the end of the article.
tools, the ones exploring all the elements of the geriatric
assessment and thereby identifying the main factors of frailty Data S1 Supporting Information.

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