Dynamic frailty assessment predicts in-hospital and early post-discharge mortality in older patients hospitalized with acute heart failure: a prospective cohort study

Frailty is insufficiently captured by conventional mortality risk scores in acute heart failure (AHF), particularly regarding its dynamic changes during hospitalization. We aimed to evaluate the relationship between different frailty assessment tools and in-hospital and 30-day post-discharge mortality in older patients hospitalized for AHF. We conducted a prospective cohort study (HOP-AHF cohort) in a second-level hospital between January 2023 and February 2024. Patients aged ≥ 80 years admitted for AHF to Acute Geriatric, Cardiology and Internal Medicine Wards were included. Frailty was assessed at baseline, within the first 48 h of admission, and at discharge using the Frail Index–VIG (FI-VIG), FRAIL scale, Clinical Frailty Scale (CFS), Tilburg Frailty Indicator (TFI) and Identification of Seniors at Risk (ISAR). The multiple estimation of risk based on the Emergency Department Spanish Score in Patients with Acute Heart Failure (MEESSI-AHF risk score) was recorded. Primary Outcome: in-hospital and within 30-day post-discharge mortality. 457 patients were included (mean age 88.60 ± 4.40 years; women 64.3%). Baseline frailty prevalence was high across all instruments (FI-VIG 84.7%, TFI 64.1%, ISAR 62.93%, CFS 60.8%, FRAIL 40.9%). In-hospital and 30-days post-discharge mortality were 8.8% and 13.0% respectively. All frailty instruments assessed at baseline and admission were associated with in-hospital mortality in univariate analyses. In multivariable models, admission frailty assessed by CFS (OR 2.26, 95% CI 1.21–4.21, p = 0.010) and TFI (OR 1.68, 95% CI 1.23–2.28 p < 0.001), together with the MEESSI-AHF score 1.42, 95% CI 1.02–1.97 p = 0.036), remained independently associated with in-hospital mortality. Frailty assessed at discharge emerged as the strongest predictor of 30-day post-discharge mortality, with FI–VIG (OR 1.75, 95% CI 1.35–2.29 p < 0.001), TFI (OR 1.24, 95% CI 1.01–1.52 p = 0.040), and MEESSI-AHF score (OR 1.22, 95% CI 1.05–1.41 p = 0.008) remaining independently associated. Frailty is highly prevalent and dynamically worsens during AHF hospitalization in older patients. Admission frailty identifies patients at risk of in-hospital death, whereas frailty at discharge captures residual vulnerability associated with early post-discharge mortality. Incorporating dynamic frailty assessment may improve prognostic stratification in AHF.