Frailty and Quality-Adjusted Survival
MEDAMACS AND INTERMACS
JoAnn Lindenfeld, MD
Professor of Medicine
Medical Director, Cardiac Transplant Program
Associate Director, Center for Women’s Health Research
University of Colorado
Frailty and Quality-Adjusted Survival
MEDAMACS 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?
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 2007;62:731-7
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 2010;56L1668-76.
Gallagher d AJP Endo 2000;297:E366-75
Barzilay JL Arch Int MEd2007;167:635-41
There are a Number of Ways to
Measure Frailty
• Frailty phenotype1
• Frailty index2
1 Fried LP et a. J Gerontol Collab Res Group 2001;56:146-5
2 Rockwood K et al. CMAJ 2005; 173:489-95
Fried Frailty Phenotype
Frailty Measure
Criteria
Scoring System
Validated Physical Performance Measures
Fried Criteria
1. Unintentional weight loss

2. Low grip strength
3. Self-reported exhaustion
A number of
studies show that
gait speed
outperforms
other criteria of
frailty
or not frail

4. Slow gait speed measured at
usual pace over 15 feet
0 criteria met: robust
1-2 criteria met:
intermediate frail

≥ 3 criteria met: frail
5. Low self-reported physical
activity
Fried LP et al. J Gerontol A. Biol Sci Med 2001;56: M146-56; Banden-Roche K et al J Gerontol
a Biol Sci Med Sci 2006;61:262-66;Xue Q-L et al. J Gerontol A. BiolSci Med Sci 2008; 63:984-990
INTERMACS and MEDAMACs
15 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*
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 2008;8:24-34
Frailty(Deficit) Index Predicts Mortality and
Rehospitalizations
Cumulative deficit index
1. Need help preparing meals
2. Need help feeding yourself
3. Need help dressing yourself
4. Need help using the toilet
5. Need help with housekeeping
6. Need help climbing stairs
7. Need help bathing
Cut-points
Yes = 1, No = 0
Yes = 1, No = 0
Yes = 1, No = 0
Yes = 1, No = 0
Yes = 1, No = 0
Yes = 1, No = 0
Yes = 1, No = 0
8. Need help walking
Yes = 1, No = 0
9. Need help using transportation
10. Need help getting in and out of bed
11. Need help managing medications
12. Depend on assistive devices (walker,
cane, etc.) or other people to perform
activities of daily life
13. Dependent on a device for normal
breathing
Yes = 1, No = 0
Yes = 1, No = 0
Yes = 1, No = 0
14. Climb 2 flights of stairs without rest
15. Myocardial infarction
16. Diabetes
17. Peripheral vascular disease
18. Cerebrovascular disease
19. Chronic obstructive pulmonary disease
20. Ulcer
21. Hemiplegia
22. Moderate/severe renal insufficiency
23. History of liver disease
24. Rheumatologic disease
25. History of malignancy
26. History of dementia
27. Hypertension
28. Hyperlipidemia
29. Body mass index
30. Depression
31. Anemia
(0.32 = frail, 0.23 to 0.32 = intermediate frail, <0.23 = not frail).
Yes = 1, No = 0
Yes = 1, No = 0
No, cannot do at all = 1; Yes, with difficulty =
0.5; Yes with no difficulty = 0
Yes = 1, No = 0
Yes = 1, No = 0
Yes = 1, No = 0
Yes = 1, No = 0
Yes = 1, No = 0
Yes = 1, No = 0
Yes = 1, No = 0
Yes = 1, No = 0
Yes = 1, No = 0
Yes = 1, No = 0
Yes = 1, No = 0
Yes = 1, No = 0
Yes = 1, No = 0
Yes = 1, No = 0
Underweight or obese = 1; overweight = 0.5;
normal = 0
Yes = 1, No = 0
Yes = 1, No = 0
Mortality and Rehospitalization
Dunlay SM et al. J HLTx 2014;33:359-65
Frailty (Handgrip) Predicts Mortality
and Improves post LVAD
*
H G S /B W
70
in
40
C h a n g e
30
%
80
0
*
N o n - D o m in a n t
60
50
n = 26
n = 31
20
*
10
-1 0
D o m in a n t
1
2
3
4
5
**
6
M o n t h s A f t e r L V A D P la c e m e n t
* p < 0 .0 5
* * p < 0 .0 0 5
Chung CJ et al. J Card Failure 2014;20:310-15
n = 72
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
MEDAMACS
Baseline A and Baseline B (n = 53)
Characteristic
Baseline A
Baseline B
Gait Speed (M/sec)
N=36
N=31
mean
1.0 (0.5)
1.1(0.4)
median
1.0(.7-1.2)
1.1(0.9-1.4)
Mean(SD)
264.3(129)
248.1(127.8)
Median(IQR)
280(182.9-321.3)
274.9(130.1-337.7)
6 minute walk
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
predict—are they different? (eg respiratory failure,
recovery to home)
• How closely does frailty correlate with quality of life?