Key result
A deficit accumulation frailty index demonstrated significantly better discrimination than the Lee index for predicting death or severe functional decline at 12 months in the overall cohort (C-statistic 0.735 vs 0.680, p=0.03) and among patients undergoing transcatheter aortic valve replacement.
Why the study?
Current guidelines recommend considering life expectancy before AVR, but the comparative performance of a general mortality index versus a frailty index was unclear.
Does a frailty index better predict death or severe functional decline at 12 months compared to the Lee index in older adults undergoing SAVR or TAVR?
Cohort (n=246)
No
Does a frailty index better predict death or severe functional decline at 12 months compared to the Lee index in older adults undergoing SAVR or TAVR?
Absolute Event Rate: 0.735% vs 0.68%
p-value: p=0.03
A multi-domain frailty index provides superior risk stratification for predicting 12-month death or severe functional decline in high-risk TAVR patients compared to the general Lee mortality index.
BACKGROUND: Current guidelines recommend considering life expectancy before aortic valve replacement (AVR). We compared the performance of a general mortality index, the Lee index, to a frailty index. METHODS: We conducted a prospective cohort study of 246 older adults undergoing surgical (SAVR) or transcatheter aortic valve replacement (TAVR) at a single academic medical center. We compared performance of the Lee index to a deficit accumulation frailty index (FI). Logistic regression was used to assess the association of Lee index or FI with poor outcome, defined as death or functional decline with severe symptoms at 12 months. Discrimination was assessed using C-statistics. RESULTS: In the overall cohort, 44 experienced poor outcome (31 deaths, 13 functional decline with severe symptoms). The risk of poor outcome by Lee index quartiles was 6.8% (reference), 17.9% (odds ratio [OR], 3.0; 95% confidence interval, [0.9-10.2]), 20.0% (OR 3.4; [1.0-11.4]), and 34.0% (OR 7.1; [2.2-22.6]) (p-for-trend = 0.001). Risk of poor outcome by FI quartiles was 3.6% (reference), 10.3% (OR 3.1; [0.6-15.8]), 25.0% (OR 8.8; [1.9-41.0]), and 37.3% (OR 15.8; [3.5-71.1]) (p-for-trend< 0.001). The Lee index predicted the risk of poor outcome in the SAVR cohort Lee index (quartiles 1-4: 2.1, 4.0, 15.4, and 20.0%; p-for-trend = 0.04), but not in the TAVR cohort (quartiles 1-4: 27.3, 29.0, 21.3, 35.4%; p-for-trend = 0.42). In contrast, the FI did not predict the risk of poor outcome well in the SAVR cohort (quartiles 1-4: 2.3, 4.4, 15.8, and 0%; p-for-trend = 0.24), however in the TAVR cohort (quartiles 1-4: 9.1, 14.3, 29.7, and 40.7%; p-for-trend = 0.004). Compared to the Lee index, an FI demonstrated higher C-statistics in the overall (Lee index versus FI: 0.680 versus 0.735; p = 0.03) and TAVR (0.560 versus 0.644; p = 0.03) cohorts, but not SAVR cohort (0.724 versus 0.766; p = 0.09). CONCLUSIONS: While a general mortality index Lee index predicted death or functional decline with severe symptoms at 12 months well among SAVR patients, the FI derived from a multi-domain geriatric assessment better informs risk-stratification for high-risk TAVR patients.
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Shi et al. (2020) conducted a cohort in Severe aortic stenosis (n=246). Frailty index vs. Lee index was evaluated on Discrimination (C-statistic) for death or functional decline with severe symptoms at 12 months (p=0.03). A deficit accumulation frailty index demonstrated significantly better discrimination than the Lee index for predicting death or severe functional decline at 12 months in the overall cohort (C-statistic 0.735 vs 0.680, p=0.03) and among patients undergoing transcatheter aortic valve replacement.
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