JoAnn Lindenfeld, MD

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Frailty and Quality-Adjusted SurvivalMEDAMACS
AND INTERMACS

• JoAnn Lindenfeld, MD
• Professor of Medicine
• Medical Director, Cardiac Transplant Program
• Associate Director, Center for Womens Health
  Research
• University of Colorado

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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?

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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
200762731-7
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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 201056L1668-76. Gallagher
d AJP Endo 2000297E366-75 Barzilay JL Arch Int
MEd2007167635-41
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There are a Number of Ways to Measure Frailty

• Frailty phenotype1
• Frailty index2

1. Fried LP et a. J Gerontol Collab Res Group
   200156146-5
2. Rockwood K et al. CMAJ 2005 173489-95

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Fried Frailty Phenotype
Frailty Measure Criteria Scoring System
Validated Physical Performance Measures Validated Physical Performance Measures Validated Physical Performance Measures
Fried Criteria Unintentional weight loss Low grip strength Self-reported exhaustion Slow gait speed measured at usual pace over 15 feet Low self-reported physical activity 0 criteria met robust or not frail 1-2 criteria met intermediate frail 3 criteria met frail
A number of studies show that gait speed
outperforms other criteria of frailty
Fried LP et al. J Gerontol A. Biol Sci Med
200156 M146-56 Banden-Roche K et al J
Gerontol a Biol Sci Med Sci 200661262-66Xue
Q-L et al. J Gerontol A. BiolSci Med Sci 2008
63984-990
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INTERMACS and MEDAMACs15 foot gait speed
Fifteen foot Gait Speed Test
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 line
Stop the timer with the first footfall after the 5-meter line
Frailty is defined by the time to walk 15 feet
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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 2008824-34
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Frailty(Deficit) Index Predicts
Mortality and
Rehospitalizations
Cumulative deficit index Cut-points
1. Need help preparing meals Yes 1, No 0
2. Need help feeding yourself Yes 1, No 0
3. Need help dressing yourself Yes 1, No 0
4. Need help using the toilet Yes 1, No 0
5. Need help with housekeeping Yes 1, No 0
6. Need help climbing stairs Yes 1, No 0
7. Need help bathing Yes 1, No 0
8. Need help walking Yes 1, No 0
9. Need help using transportation Yes 1, No 0
10. Need help getting in and out of bed Yes 1, No 0
11. Need help managing medications Yes 1, No 0
12. 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 0
16. Diabetes Yes 1, No 0
17. Peripheral vascular disease Yes 1, No 0
18. Cerebrovascular disease Yes 1, No 0
19. Chronic obstructive pulmonary disease Yes 1, No 0
20. Ulcer Yes 1, No 0
21. Hemiplegia Yes 1, No 0
22. Moderate/severe renal insufficiency Yes 1, No 0
23. History of liver disease Yes 1, No 0
24. Rheumatologic disease Yes 1, No 0
25. History of malignancy Yes 1, No 0
26. History of dementia Yes 1, No 0
27. Hypertension Yes 1, No 0
28. Hyperlipidemia Yes 1, No 0
29. Body mass index Underweight or obese 1 overweight 0.5 normal 0
30. Depression Yes 1, No 0
31. Anemia Yes 1, No 0
(0.32 frail, 0.23 to 0.32 intermediate frail,
lt0.23 not frail).
Mortality and Rehospitalization
Dunlay SM et al. J HLTx 201433359-65
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Frailty (Handgrip) Predicts Mortality
and Improves post LVAD
n 26
n 31
n 72
Chung CJ et al. J Card Failure 201420310-15
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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

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MEDAMACS Baseline A and Baseline B (n 53)
Characteristic Baseline A Baseline B
Gait Speed (M/sec) N36 N31
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)
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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 predictare they different? (eg
  respiratory failure, recovery to home)
• How closely does frailty correlate with quality
  of life?