Frailty in pulmonary hypertension: Establishing the frailty index and impact on survival

BACKGROUND: Patients with pulmonary hypertension (PH) experience reduced physical capacity, which affects daily life functionality. Frailty signifies increased vulnerability due to diminished physiological reserves and is common in the elderly and those with chronic diseases, but has not been investigated in PH. This study aimed to create a frailty index for PH, to assess the prevalence of frailty, to determine frailty severity and progression over time and to establish a potential association between frailty and mortality in patients with PH. METHODS: This retrospective cohort study included patients with right heart catheter confirmed PH. Frailty was assessed using a cumulative frailty index (FI). Logistic regression, Cox proportional hazard models and causal mediation analyses were used to determine the relationship between frailty and time from FI assessment to death or censoring. RESULTS: After dropping 22 items with item-score correlation <0.7, a 30-item-FI was developed, demonstrating high internal consistency. At baseline 117/189 (62 %) patients were frail (FI > 0.12) and this proportion increased to 71 % at follow-up. Frail patients were older, had lower 6-min walk distance (6MWD), higher NT-proBNP, and lower pulmonary vascular resistance (PVR). Risk of death was significantly higher in patients with frailty after adjustment for age, sex, PVR, and PH treatment (HR 6.4, 95 % CI 2.14-19.1, p = 0.001); only a small proportion of this effect was mediated by 6MWD. CONCLUSIONS: Frailty is common in PH and an independent risk factor for mortality beyond confounding/effect modification. Future research should explore underlying mechanisms and the utility of integrating frailty assessment in routine PH patient care.