e-ISSN : 2149-8156
Turkish Journal of Thoracic and Cardiovascular Surgery     
Which frailty score in cardiac surgery patients?
Seyhan Babaroğlu1, Ayşen Aksöyek1, Ali Eba Demirbağ2, İlknur Günaydın1
1Department of Cardiovascular Surgery, Ankara Bilkent City Hospital, Ankara, Türkiye
2Department of Gastrointestinal Surgery, Ankara Bilkent City Hospital, Ankara, Türkiye
DOI : 10.5606/tgkdc.dergisi.2025.26954

Abstract

Background: Frailty assessment for risk prediction is suggested in elderly patients undergoing cardiac surgery. We aimed to compare five different frailty tests.

Methods: Relation of Edmonton Frailty Score (EFS), Fried Frailty Phenotype (FFP), FRAIL (Fatigue, Resistance, Ambulation, Illness, and Loss of weight), Katz and hand grip strength (HGS) tests to each other, postoperative outcomes and mortality rates were evaluated prospectively in 140 consecutive patients aged ≥65 years.

Results: The median follow-up period was 880.5 (range, 0 to 1,237) days with higher EFS and FFP scores in non-survivors (p<0.05). Patients with any complication had higher EFS (p=0.002), FFP (p=0.004) and FRAIL (p=0,006) scores. Compared to non-frail patients, frail patients" NYHA capacity, EuroSCORE II and STS mortality risks were higher; hemoglobin values and HGS were lower with EFS, FFP, and FRAIL tests. Frail patients" hospitalization periods with EFS (p=0.003) and intensive care unit stay with FFP (p=0.029) were longer. No mortality was observed in non-frail patients according to the FFP test. The Kaplan-Meier (KM) log-rank survival curves showed significant differences in favor of non-frail subgroups according to EFS, FFP and HGS tests (p<0.05). Relative risks for mortality in frail and pre-frail patients were between 0.9 and 4. The FFP was the most sensitive test (area under curve=0.721). There was discordance rather than concordance among five different tests (Kappa <0.411).

Conclusion: For patients aged ≥65 years undergoing heart surgery the FFP can be used safely to determine non-frail patients. Although the EFS seems to be promising to identify frail patients, further large-scale studies using various tests are needed to predict an optimal cut-off value for this patient population.

Frailty is described as a biological syndrome characterized by a decline in physiological reserve and being more fragile to stressors such as acute or chronic illnesses or surgical procedures with resultant adverse health outcomes.[1,2] Being a greats tressor, cardiac surgery deals with more elderly patients with worse clinical profiles, as life expectancy increases. Frailty screening for elderly patients objectively may have important aspects for risk reduction by taking preoperative precautions to increase the strength of the patients such as nutritional support, respiratory muscles reinforcement, exercise, and treatment of reversible comorbidities such as hypothyroidism, anemia, or depression. There are numerous frailty tests which differ widely with respect to their evaluation criteria and with no consensus on the most optimal test to be used preoperatively according to cardiac surgery guidelines.[3-6]

The number of studies regarding frailty assessment before cardiac surgery in Turkish literature is extremely limited and there is an unmet need for deciding surgery or otherwise less invasive percutaneous procedures in elderly and seemingly frail patients.[7] In the present study, we aimed to compare five frailty tests with different properties, namely Edmonton Frailty Scale (EFS), Fried Frailty Phenotype (FFP), Fatigue, Resistance, Ambulation, Illness, and Loss of weight (FRAIL), Katz, and hand grip strength (HGS) tests, and to evaluate concordance/discordance between the test pairs. Our secondary objective was to identify the most useful test in cardiac surgery patients for future use.

Methods

Study design and study population
This single-center, prospective study was conducted at Ankara Bilkent City Hospital, Department of Cardiovascular Surgery between September 2021 and February 2023. Patients who were scheduled for cardiac surgery were screened. Inclusion criteria were as follows: age ≥65 years; having coronary artery disease and/or heart valve pathology or ascending and/or aortic arch aneurysm. Exclusion criteria were as follows: emergent cases, age <65 years or having either mental or physical disability precluding the patients from performing the tests. No patient was denied surgery based on detected frailty level and the surgeons were blinded to the test results. Finally, a total of 140 consecutive patients (92 males, 48 females; mean age: 70.0±4.0; range, 65 to 84 years) who met the inclusion criteria were recruited. A written informed consent was obtained from each patient. The study protocol was approved by the Ankara City Hospital Clinical Research (date: 28.04.2021, no: E1-21-1775). The study was conducted in accordance with the principles of the Declaration of Helsinki.

Data collection and definitions
Demographics, comorbidities, and pre- and postoperative data were recorded. The European System for Cardiac Operative Risk Evaluation (EuroSCORE II) and Society of Thoracic Surgeons (STS) mortality and morbidity risks (renal failure, cerebrovascular accident, prolonged ventilation, re-operation, morbidity, and prolonged hospitalization) were calculated for each patient.

Hospital mortality was defined as the mortality occurred during the index hospitalization of the patient even after 30 days. Late mortality was defined as mortality occurring after 30 days following discharge. Complications were defined as prolonged ventilation (mechanical ventilatory support lasting more than 24 h), the presence of deep sternal infection (requiring operative intervention), pneumonia (positive cultures with radiological evidence), psychological (any disorder requiring medical therapy), acute renal failure (new requirement for dialysis), stroke (symptoms not resolving after 24 h), re-operation (surgical re-exploration due to bleeding with or without any cardiac problem), atrial fibrillation, postoperative inotropic medication (lasting more than 24 h with more than one type of inotropic agent), incision complication (any incision requiring debridement or secondary suturing with positive wound culture), sepsis (positive blood culture requiring intense antibiotic therapy).

Frailty tests
The patients were asked to perform EFS, FFP, FRAIL, and Katz questionnaire.[1,2,5,6,8] The term prefrailty or vulnerability is used to define a condition predisposing to frailty. The EFS has 10 domains, two of which measure physical performance (time to get-up, walk 3 m then back and sit down) and cognitive ability. The rest are questions about mood, functional independence, medications, nutrition, social support, continence, and general health status. The score ranges between 0 and 17, with cut-off values for frailty ≥8, pre-frailty 6-7, and non-frailty ≤5 points.[8] The FFP scale has two domains to test upper (hand grip) and lower extremity (walking speed) strength and three questions regarding unintentional weight loss, exhaustion, or low physical activity. Deficiency in ≥3 features is defined as frailty, 1 or 2 features as pre-frailty.[1] Both tests take 10 to 15 min according to the educational and physical capability of the patient. The FRAIL test questions five items; fatigue, resistance, ambulation, illnesses, and weight loss.[2] One or 2 points indicates pre-frailty and ≥3 points frailty. The Katz test is the quickest test to question dependency of the patient about six activities of daily living (ADL; (bathing, dressing, toileting, transferring, continence, feeding) and ≥1 insufficiency is regarded as dependency.[5] Both tests last less than 5 min. Hand grip strength was performed three times with a digital electronic equipment and the strongest value was recorded (Kyto 2326, Guangdong China). Weakness was defined according to predefined FFP stratified body mass index cut-off values for each sex and patients were grouped as HGS weak or normal.[1]

Statistical analysis
Sample size was calculated based on mortality rates of 14.7% in frail and 4.5% in non-frail patients according to Katz ADL test, and 131 patients for each group were found to be sufficient. Upon reaching 140 patients in total, post-hoc power analysis were 87.9%, 96.8%, 51.6%, 9.2%, and 11.5% for the EFS, FFP, FRAIL, Katz and HGS scores, respectively. As 80% power was exceeded with the EFS and FFP tests we decided to terminate the study.

Statistical analysis was performed using the IBM SPSS version 24.0 software (IBM Corp., Armonk, NY, USA). Continuous data were expressed in mean ± standard deviation (SD) or median (min-max), while categorical data were expressed in number and frequency. Relative risks for mortality were calculated by dividing incidence of a risk variable in non-survivors to that of survivors. Frailty tests in the survivors and non-survivors were analyzed with receiver operating characteristic (ROC) analysis and area under the curve (AUCs) were calculated. Categorical variable distributions were compared in cross tables between the two groups with chi-square and Fisher exact tests. The Mann-Whitney U test was used to compare continuous variables between the two, and the Kruskal-Wallis test for multiple groups. After Kruskal-Wallis tests, significant pairs were identified by Bonferroni post-hoc multiple comparison test. The kappa (k) statistics were used to test concordance or discordance between pairs of five frailty tests. The Kaplan-Meier test was used for survival analysis and the subgroups were compared by using log-rank test. Correlations between each frailty test, and New York Heart Association (NYHA), STS, or EuroSCORE II were calculated using the Spearman correlation test. A p value of <0.05 was considered statistically significant with 95% confidence interval (CI).

Results

The median follow-up was 808.5 (range, 0 to 1,237) days. Isolated coronary artery bypass grafting (CABG) surgery was performed in 58.6% and valve surgery in 21.4% of the patients. Aortic surgery and, CABG with valve surgery, were 10% for each. Demographics, procedures, and pre- and postoperative data are given in Supplement Tables 1 and 2. Fifty-seven patients (40.7%) experienced at least one complication in the postoperative period. Except Katz questionnaire, there were significant differences regarding the median frailty scores between patients with complicated and non-complicated postoperative courses: 4.0 vs. 3.0 for EFS (p=0.002), 2.0 vs. 1.0 for FFP (p=0.002), and 2.0 vs. 1.0 for FRAIL (p=0.002), 6.0 vs. 6.0 for Katz (p=0.306), and 25.6 kg vs. 29.6 kg for HGS (p=0.025), respectively.

In the present study, frail patients constituted 4.3 to 24.3% of the patients (EFS 4.3%, FFP 24.3%, and FRAIL 23.6%) with more prevalent pre-frail patients (EFS 10.7%, FFP 66.4% and FRAIL 50.7%) according to scales used.

Hospital mortality rate was 5.3% (n=7) and overall mortality was 14.3% (n=13). Owing to enough sample size, EFS and FFP scores both as scale and ordinal, HGS only as ordinal parameter were significantly higher in non-surviving patients compared to survivors (p<0.05 for all) (Table 1). The FRAIL, Katz tests did not reveal any significant difference. Survival rates decreased significantly according to Kaplan-Meier log-rank test, as patients became frailer according to EFS, FFP frailty tests, and HGS test (Figure 1). Relative risks for mortality were between 0.9 and 4.6-fold in frail patients compared to the nonfrail patients (Table 1).

Table 1. Frailty tests between surviving and non-surviving groups and relative risks for mortality

Figure 1. Survival of patients" subgroups according to EFS, FFP scorings and hand grip strength. (a) Edmonton frailty score (p=0.001). (b) FRIED frailty score (p=0.001). (c) Hand grip strength (p=0.008)
EFS: Hand grip strength; FFP: Fried frailty phenotype; HGS: Hand grip strength.

According to EFS and FFP tests, there were statistically significant differences among non-frail, pre-frail, and frail patients regarding preoperative variables (NYHA, hemoglobin, STS and EuroSCORE II risks, and HGS) in favor of non-frail patients. Among postoperative variables, the length of hospital stay in EFS, the length of intensive care unit (ICU) stay, complications, and the need for inotropic support in FFP was also better in non-frail patients (Tables 2 and 3). Although significant differences were observed regarding these preoperative characteristics in patient subgroups according to FRAIL test, no significant difference occurred in the postoperative outcomes (Table 4).

Table 2. Demographics, preoperative characteristics, and postoperative results of the patients according to the EFS frailty subgroups

Table 3. Demographics, preoperative characteristics, and postoperative results of the patients according to the FFP frailty subgroups

Table 4. Demographics, preoperative characteristics, and postoperative results of the patients according to the FRAIL test frailty subgroups

According to the Katz ADL questionnaire, the aforementioned baseline parameters, excluding EuroSCORE II mortality risk, were different between dependent or non-dependent patients. Considering postoperative outcomes, only transfused red blood cell amount was higher in the dependent group (p=0.021) (Table 5).

Table 5. Demographics, characteristics, and postoperative results of the patients according to Katz ADL subgroups

In patients with normal HGS, left ventricular ejection fraction, hemoglobin, albumin levels, STS, and EuroSCORE II risks, complication rates, the need for inotropic support, length of hospital stay were significantly different than those with weak HGS (Table 6).

Table 6. Demographics, preoperative characteristics, and postoperative results of the patients according to the hand grip strength

A significant positive correlation was found between each frailty score and patients" NYHA functional class (p<0.001 for all). Other than the Katz ADL questionnaire, frailty scores were positively correlated with EuroSCORE II and STS's predicted mortality risks (p<0.001 for all), and major STS morbidity risk score values (p<0.001 for all), except for deep sternal wound risk.

Considering the concordance rates, we observed discordance between all other pairs (k<0.200), except for a moderate (0.411) and fair (0.270) concordance between FFP and FRAIL, and FFP and Katz tests, respectively (Supplement Table 3).

According to the ROC curve analysis, the AUC values of five assessment methods reached the highest for FFP scoring with 0.721 (95% CI: 0.598-0.843) (Figure 2).

Figure 2. ROC analyses of five different frailty tests with AUC, significance and 95%CI. The test result variable(s): EFS, FREID, FRAIL, KATZ, Hand Grip Strength has at least one tie between the positive actual state group and the negative actual state group.
ROC: Receiver operating characteristic; FRAIL: Fatigue, Resistance, Ambulation, Illness, and Loss of weight; CI: Confidence interval; SE: Standard error; EFS: Hand grip strength; FFP: Fried frailty phenotype; HGS: Hand grip strength.

Discussion

In the present study, we compared five frailtytests with different properties, namely EFS, FFP,FRAIL, Katz, and HGS tests, and identified the mostuseful test in cardiac surgery patients for future use.Our study results showed that the NYHA class offrail patients, hemoglobin values, EuroSCORE IIand STS risk scores, and HGS values were lowercompared to non-frail patients. Frail patients alsoexperienced more postoperative complications(in FFP and HGS), prolonged hospital (in EFS andHGS) or ICU stay (in FFP), compared to non-frailpatients. These findings are consistent with theresults of previous published series in which frailpatients were more likely to have higher STS andEuroSCORE II risk scores and worse postoperativeoutcomes, and longer length of hospital and ICUstay.[9-13] In a recent meta-analysis, frailty wasassociated with three-fold greater risk of operativemortality (RR: 2.99, 95% CI: 2.34-3.82, p<0.00001)which differed between 2.9- and 4.6-fold in thepresent study according to test used.[9]

In a study conducted with FFP test and a similarpatient cohort, the prevalence of frailty (23%),postoperative hospital (8 vs. 5 days) a nd I CU stay(54 vs. 28 h), and postoperative complications(54% vs. 3 2%) i n f rail p atients c ompared t o t he non-frail patients were similar to the present study;however, this difference regarding postoperativeoutcomes was not observed after multivariateadjustments.[10] Henry et al.[14] also found nosignificant difference in adverse clinical outcomesin frail patients other than discharge to home(60.9% vs. 85.6%) in contrast to our study.[14] Thepatient cohort did not permit multivariate analysisin the present study, but the most striking findingfor FFP was its ability to discriminate non-frailpatients who would benefit from open heart surgerymost with 0% mortality rate. Non-frail patients wererepresented with a relatively small ratio in our cohort(9.3%) compared to other studies (76.5%[10] and72.5%[14]); however, the study power for mortalitycalculation in FFP subgroups was (96.8%) enoughto arrive at this conclusion. The FFP test evaluatesmuscle function with objective measurement ofHGS with a special instrument and walking speed inaddition to questions regarding unintentional weightloss, exhaustion, or low physical activity withoutany difficulty to the patient. Lower HGS cut-offvalues were suggested for Turkish population aged≥59 years in a recent study which may, in part,explain higher prevalence of pre-frail patients in ourcohort that might have otherwise been accepted asnon-frail.[15]

Several modifications have been proposed whichmay further increase the discriminating value of theoriginal FFP test at the expense of lengthening andcomplicating the procedure. Addition of GeriatricDepression Scale and the Montreal CognitiveAssessment frailty revealed 2- to 3.5-fold higher riskof poor functional survival one year after cardiacsurgery in frail patients which was 3.3 with simple FFPtest in the present study.[16] Being frail was associatedwith 1.36 times higher risk for mortality or majormorbidity according to FFP test with an AUC 0.60concordant with the present study (AUC=0.743).[17]We believe that simple FFP test may suffice to predicthospital outcomes of particularly non-frail patientsby predominantly objective evaluation of upper andlower extremity strength of the patients within areasonable time frame, as sarcopenia related poormobilization may have deleterious effects in the earlypostoperative period. Inclusion of cognitive ability anddepression tests may add further value in the longterm,when motivation for self-maintenance requires bettercognitive abilities and mood.

A multi-dimensional test with objectiveassessment of walking performance(Get-Up-and-Go), as well as evaluating mood, medication, nutrition, functional independence,cognitive function, and social support of anindividual EFS test was another test with whichwe had better performance. Lal et al.[11] reportedthat frail patients according to EFS test were older,had lower preoperative hemoglobin values andlonger hospital stay compatible with the presentstudy. With a similar cohort of 309 patients but ahigher frailty prevalence (61.3%), Castro et al.[18]also identified reduced survival in one year aftersurgery. In patients aged Quote Sing. Base75 years and 20% withsome degree frailty, EFS was a good predictor for30-day mortality with an AUC of 0.69 in anotherstudy.[19] These values are 15% with an AUC of 0.701in the present study.

Unlike FFP, the FRAIL test was not commonlyused in cardiac surgery, but was reported topredict physical limitation and mortality of olderindividuals in epidemiological studies.[13] Relyingon five-item self-reported queries, it is a ratherquick but subjective test. In an epidemiologicalstudy in Turkish population aged ≥60 years, theAUC was estimated as 0.672 and 0.588 for the FFPand FRAIL, respectively.[20] The FFP is a strongerpredictor than FRAIL scale for mortality in thisstudy, as well (AUC=0.721 vs. 0.626).

As a referred frailty assessment tool in 2021ESC guidelines, the Katz ADL was an independentrisk factor for in-hospital mortality in earlierstudies.[5,8] Lee et al.[21] reported a higher hospitalmortality rate among frail patients comparedto non-frail patients (14.7% vs. 4.5%). Variouscomplications, transfusion, prolonged length ofstay and ventilation were also more commonin functionally dependent patients. Only higherblood transfusion requirements were observedpostoperatively in dependent patients accordingto the Katz test in the present study. Odds ratiofor in-hospital mortality for Katz was 0.98 andAUC was 0.48 in the aforementioned study, whilethese values were 0.7 and 0.565, respectively inthe present study. However, these results should beinterpreted cautiously, as the study power for Katztest in our study was very low (9.2%, n=140) and asit would require more than 3,800 patients for a morepowerful study (80%) according to our results.

We believe that muscle function assessment is anessential part of frailty screening. The five-m gaitspeed, which is a component of FFP and EFS tests,was predictive of both mortality and major morbidityin a multi-center study and offered as a test of frailtyin STS Adult Cardiac Database version 2.73.[6,22]

In the EuroSCORE II "poor mobility" was includedwithout any reference to a significant test.[6,23] Anindicator of muscle strength and a component of FFPtest, HGS may prove useful where joint problemsmay preclude proper walking speed. Increased HGSwas found to be associated with decreased all-causemortality and ICU length of stay in a study whereHGS was evaluated with bioelectrical impedance.[24]In the present study, weaker HGS was linked tolonger length of hospital stay, higher complicationand mortality rates with decreased survival andhigher need for postoperative inotropic medicine.

Frail patients constituted 4.3 to 24.3%, and pre-frailpatients constituted 10.7 to 66.4% of our wholecohort according to the test used, indicating a highlevel of disparity. Since frailty tests differ widely incomposition, frailty prevalences also differ in theliterature.[4,13,14] Some tests rely only on subjectivequestions (Katz and FRAIL tests), while others mayincorporate objective physical strength measurementor cognitive function tests in varying proportions.There was discordance between most test pairs whichmay explain the diversity of frailty prevalence foundin the present study. As socioeconomic, culturaland educational factors may have implicationsfrom patients" perspective during test performance,validation studies for frailty tests are usually carriedout in most countries. One of these studies for FFP testfound lower HGS cut-off values for Turkish populationaged ≥59 years to be in good agreement.[15] Studiesconducted according to these national validation testcut-off values in Turkish population may yield morecomparable frailty prevalence.

One of the main limitations to the present studyis its relatively small sample size and short follow-upperiod for multivariate analysis. Calculated studypowers were 87.9% for EFS score and 96.8% forFFP; therefore, we decided to publish our preliminaryresults. Of note, thousands of patients were requiredfor the Katz test to reach 80% of study power. Also,studies conducted with validated HGS cut-off valuesfor Turkish population may be more expedient. Studiesevaluating validation and reliability of these five testsconducted with patients aged ≥65 years are needed toarrive at an optimum conclusion.

In conclusion, among patients aged 65 yearsand over undergoing cardiac surgery, frail patientsdemonstrated higher mortality rates with eithermore frequent postoperative complications, longerhospital or ICU stay compared to non-frail patientsaccording to the test used. These findings underscorethe importance of frailty assessment before cardiac surgery. Among these five tests, the FFP test wasthe strongest in identifying non-frail patients inunivariate analysis and survival comparisons andpatients classified as non-frail according to thistest can be safely referred to surgery. Since thereare components that evaluate muscle strength, it isconcluded that FFP and EFS tests may prove useful indetecting frail patients. The Katz, FRAIL, and HGStests were found to be less powerful with 140 patientsto identify either frail or non-frail patients. Thisdifference among these five frailty tests was alsocorroborated with resultant discordance betweeneach test pair in the present study. Further large-scalestudies with more patients using various tests areneeded to predict cut-off values to determine frailtyin cardiac surgery patient population.

Acknowledgements: Authors would like to thank toNuman Ertuğrul Babaroğlu for his great contribution fordocumentation.

Data Sharing Statement: The data that support the findingsof this study are available from the corresponding author uponreasonable request.

Author Contributions: Idea/concept, design: A.A.; Control/supervision: S.B., A.A., A.E.D.; Data collection and/or processing:S.B., A.A., A.E.D., İ.G.; Analysis and/or interpretation: S.B.,A.A., A.E.D.; Epidemiological and statistical decision making:A.E.D.; Literature review, references: S.B., A.A., İ.G.; Writingthe article, critical review: S.B., A.A., A.E.D.; Materials: S.B.;Other: S.B., A.A.

Conflict of Interest: The authors declared no conflicts ofinterest with respect to the authorship and/or publication of thisarticle.

Funding: The authors received no financial support for theresearch and/or authorship of this article.

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Keywords : Cardiac surgery, elderly, frail, frailty
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