Frailty and Heart Failure: An Integrated Review of a Bidirectional Relationship

Abstract Heart failure (HF) and frailty frequently coexist in older adults and are associated with poor clinical outcomes. Frailty affects 15–76% of patients with chronic HF depending on the clinical setting and assessment tool used, with prevalence approaching 90% in hospitalised patients with heart failure with preserved ejection fraction (HFpEF). This integrated review synthesises current evidence on the bidirectional relationship between frailty and HF, including shared pathophysiological mechanisms, epidemiology, prognostic implications, assessment strategies, and contemporary management approaches. Available evidence indicates that frailty independently predicts incident HF and is associated with progressive deterioration in cardiac structure and function. Conversely, HF accelerates frailty progression through systemic inflammation, skeletal muscle hypoperfusion, sarcopenia, neurohormonal activation, malnutrition, and hospital-associated deconditioning. Frailty contributes to impaired quality of life, reduced self-care capacity, prolonged hospitalisation, poorer tolerance of guideline-directed medical therapy, and higher all-cause mortality risk. Current assessment strategies include physical performance measures, multidimensional frailty instruments, and comprehensive geriatric assessment. The recently developed Heart Failure Frailty Score (HFFS) represents the first HF-specific multidimensional frailty instrument. Management strategies include exercise rehabilitation, nutritional optimisation, structured medication review, and integration of frailty assessment into advanced HF decision-making. Future research should prioritise prospective validation of HF-specific frailty tools and randomised trials evaluating frailty-targeted interventions in HF populations.