Cognitive impairment improves the predictive validity of physical frailty for mortality in patients with advanced heart failure referred for heart transplantation.
The aim of this study was to identify whether the addition of cognitive impairment, depression, or both, to the assessment of physical frailty provides better outcome prediction in patients with advanced heart failure referred for heart transplantation (HT).



Beginning in March 2013, all patients with advanced heart failure referred to our Transplant Unit have undergone a physical frailty assessment using the Fried frailty phenotype. Cognition was assessed with the Montreal Cognitive Assessment and depression with the Depression in Medical Illness questionnaire. We assessed the value of 4 composite frailty measures: physical frailty (PF ≥ 3 of 5 = frailty), "cognitive frailty" (CogF ≥ 3 of 6 = frail), "depressive frailty" (DepF ≥ 3 of 6 = frail), and "cognitive-depressive frailty" (ComF ≥ 3 of 7 = frail) in predicting outcomes.



Frailty was assessed in 156 patients (109 men, 47 women), aged 53 ± 13 years, and with a left ventricular ejection fraction of 27% ± 14%. Inclusion of cognitive impairment or depression in the definition of frailty increased the proportion classified as frail from 33% using PF to 42% using ComF. During follow-up, 28 patients died before ventricular assist device implantation or HT. Frailty was associated with significantly lower ventricular assist device- and HT-free survival, with CogF best capturing early mortality: 12-month survival for non-frail and frail cohorts was 81% ± 5% vs 58% ± 10% (p < 0.02) using PF and 85% ± 5% vs 56% ± 9% (p < 0.002) using CogF. Combining the Depression in Medical Illness score with PF or CogF did not strengthen the relationship between frailty and mortality.



The addition of cognitive impairment to the assessment of PF strengthened its capacity to identify advanced heart failure patients referred for HT who are at high risk of early death.
Heart Transplant Program, St Vincent's Hospital; Centre for Cardiovascular and Chronic Care, Faculty Health, University of Technology Sydney.
Sunita R
SR
Jha
Heart Transplant Program, St Vincent's Hospital; Department of Occupational Therapy.
Malin K
MK
Hannu
Department of Occupational Therapy.
Keren
K
Gore
Centre for Cardiovascular and Chronic Care, Faculty Health, University of Technology Sydney.
Sungwon
S
Chang
Heart Transplant Program, St Vincent's Hospital; Centre for Cardiovascular and Chronic Care, Faculty Health, University of Technology Sydney.
Phillip
P
Newton
Consultation Liaison Psychiatry, St Vincent's Hospital; Faculty of Medicine, University of New South Wales.
Kay
K
Wilhelm
Heart Transplant Program, St Vincent's Hospital; Faculty of Medicine, University of New South Wales; Victor Chang Cardiac Research Institute.
Christopher S
CS
Hayward
Heart Transplant Program, St Vincent's Hospital; Faculty of Medicine, University of New South Wales; Victor Chang Cardiac Research Institute.
Andrew
A
Jabbour
Heart Transplant Program, St Vincent's Hospital.
Eugene
E
Kotlyar
Heart Transplant Program, St Vincent's Hospital.
Anne
A
Keogh
Heart Transplant Program, St Vincent's Hospital.
Kumud
K
Dhital
Heart Transplant Program, St Vincent's Hospital.
Emily
E
Granger
Heart Transplant Program, St Vincent's Hospital.
Paul
P
Jansz
Heart Transplant Program, St Vincent's Hospital; Faculty of Medicine, University of New South Wales; Department of Cardiothoracic Surgery, St Vincent's Hospital, Sydney, New South Wales, Australia.
Phillip M
PM
Spratt
Heart Transplant Program, St Vincent's Hospital.
Elyn
E
Montgomery
Heart Transplant Program, St Vincent's Hospital.
Michelle
M
Harkess
Heart Transplant Program, St Vincent's Hospital.
Peta
P
Tunicliff
Centre for Cardiovascular and Chronic Care, Faculty Health, University of Technology Sydney; Faculty of Nursing, Johns Hopkins University, Baltimore, Maryland.
Patricia M
PM
Davidson
Heart Transplant Program, St Vincent's Hospital; Faculty of Medicine, University of New South Wales; Victor Chang Cardiac Research Institute. Electronic address: peter.macdonald@svha.org.au.
Peter S
PS
Macdonald
D000368:Aged; D060825:Cognitive Dysfunction; D005260:Female; D016330:Frail Elderly; D000073496:Frailty; D006333:Heart Failure; D016027:Heart Transplantation; D006801:Humans; D008297:Male
cognitive impairment; heart transplantation; physical frailty; survival; ventricular assist device